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Cancer Epidemiology Biomarkers & Prevention Vol. 15, 1515-1519, August 2006
© 2006 American Association for Cancer Research

Differences in Cancer Incidence among Indians in Alaska and New Mexico and U.S. Whites, 1993-2002

Janet J. Kelly1, Anne P. Lanier1, Steven Alberts2 and Charles L. Wiggins3

1 Office of Alaska Native Health Research, Community Health Services, Alaska Native Tribal Health Consortium, Anchorage, Alaska; 2 Department of Oncology, Mayo Clinic, Rochester, Minnesota; and 3 Epidemiology and Cancer Control, Cancer Research and Treatment Center, University of New Mexico, Albuquerque, New Mexico

Requests for reprints: Janet J. Kelly, Office of Alaska Native Health Research, Community Health Services, Alaska Native Tribal Health Consortium, 4000 Ambassador Drive, Suite 118, Anchorage, AK 99508. Phone: 907-729-3949. E-mail: jjkelly{at}anthc.org


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Cancer incidence for American Indians and Alaska Natives is typically reported as a single rate for all U.S. indigenous populations combined. Previously reported combined rates suggest that American Indians and Alaska Natives have lower cancer incidence rates compared with the U.S. population. Alaska Native people comprise three major ethnic groups: Eskimo, Indian, and Aleut people. We examined cancer incidence from only Alaska Indians and compared incidence rates with an American Indian population living in New Mexico. These data indicate striking differences in cancer patterns between two American Indian populations. Cancer data for the years 1993 to 2002 for American Indians of New Mexico and U.S. Whites are from the National Cancer Institute Surveillance, Epidemiology, and End Results Program Public-use data set. Data for Alaska Indians are from the Alaska Native Tumor Registry, which is also a Surveillance Epidemiology and End Results Program participant. Overall, cancer incidence rates for all sites combined in New Mexico Indian men and women were lower than U.S. White rates, whereas Alaska Indian men and women exceeded U.S. rates. In comparing Alaska and New Mexico Indians, we observed a 2.5-fold higher incidence of cancer among Alaska Indians. The largest differences between the two Indian populations were noted primarily in cancers associated with tobacco use, including cancers of the oral cavity/pharynx, esophagus (only in men), colon and rectum, pancreas, larynx (men), lung, prostate, and urinary bladder (men). Lung cancer rates in Alaska Indian men and women were 7 and 10 times those of New Mexico Indian men and women. (Cancer Epidemiol Biomarkers Prev 2006;15(8):1515–9)


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
U.S. cancer incidence rates by race have been reported primarily for White, Black, and more recently, Asian/Pacific Islander groups (1). Cancer incidence data for other race or ethnic groups are more limited, particularly for the indigenous peoples of North America. The indigenous population in the United States includes multiple groups with diverse language, cultural, and lifestyle practices. Currently, the most detailed incidence data are available for Alaska Native people (Eskimo, Aleut, and Indian) and American Indians from New Mexico. Cancer reports for Alaska Natives and American Indians of New Mexico indicate that cancer incidence rates for certain cancer sites differ significantly from incidence rates in the U.S. White and other U.S. racial and ethnic populations (2-5). Cancer mortality data give further evidence that patterns of cancer differ between Alaska Natives and American Indians of other geographic regions in the United States. For the years 1994 to 1998, the Indian Health Service reported cancer mortality among Alaska Natives (201 per 100,000) as more than twice the rate of American Indians of the southwest region (Arizona, Colorado, Nevada, New Mexico, and Utah Indian populations combined; 101 per 100,000; ref. 6). During a recent 5-year period, 1998 to 2002, the overall cancer mortality rate in Alaska Natives was nearly twice that of New Mexico Indians (254 versus 132 per 100,000; ref. 7).

In the Census 2000, ~120,000 persons living in Alaska reported their race as American Indian or Alaska Native, either alone or in combination with another race. The Alaska Native population is composed of Eskimo (52%), Aleut (12%), and Indian (36%). Indians in Alaska include Athabascans, who reside primarily in the interior of the state and around Cook Inlet, and Tlingit, Haida, and Tsimshian Indians, who reside in the southeastern part of the state. American Indian linguists and anthropologists suggest that Alaska Indians have close language and cultural ties with Apache and Navajo Indians of southwest United States and that Alaska Indians may have a closer relationship to Indians in the southwest United States than to Eskimo or Aleut people of Alaska (8-10). Indians living in New Mexico are predominantly people of the Navajo, Apache, Zuni, and Pueblo tribes. This report provides a comparison of cancer incidence rates for the period 1993 to 2002 among only the Indian people in Alaska and New Mexico and U.S. Whites.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Data on Alaska Indian cancers are from the Alaska Native Tumor Registry maintained at the Alaska Native Medical Center in Anchorage. The population-based registry includes all Alaska Native people, eligible for health care through the Indian Health Service and its contractors, who were diagnosed with invasive cancer while resident of Alaska from 1969 to the present. Alaska Native cancer data are the result of extensive active case surveillance whereby hospital inpatient and outpatient records are identified based on discharge diagnoses, hospital tumor registries, and pathology reports. The statewide Alaska Cancer Registry established in 1996 collects cancer information on people of all races and collaborates with the Alaska Native Tumor Registry to correctly classify by race all reported cancer cases in Alaska.

The University of New Mexico in Albuquerque maintains the New Mexico Tumor Registry for all residents of the state since 1973. Both Alaska Native and New Mexico tumor registries are participants in the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program. Methods of data collection and coding for both registries have been reported previously and follow SEER guidelines (5, 11). Public-use data sets made available by SEER classify all American Indians and Alaska Natives in a single American Indians and Alaska Natives race category. In Alaska, certification of American Indian or Alaska Native status is required to receive medical services at Native health facilities and hospitals. Ethnic classification is self-reported. Only Alaska Native people who identified themselves as Indian are included in this analysis.

Alaska Indian population estimates used in rate calculations were obtained by applying 1990 census age/gender distributions for Indians to the National Center for Health Statistics bridged census 2000 population estimate for Alaska Natives. The 1990 census allowed for specific race designation of Alaska Indian. Incidence rates for New Mexico American Indians and U.S. Whites were calculated using SEER Stat (12) and the SEER Public-use cancer incidence data set (SEER 13 reg, November 2004). Population estimates for American Indians of New Mexico and U.S. Whites are from the National Center for Health Statistics census 1990 and 2000 (bridged) population estimates. All rates were age adjusted to the U.S. 2000 standard population and compared using odds ratio calculations done in Epi Info software (13).


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
During the period of 1993 to 2002, a total of 1,185 invasive cancers were newly diagnosed among Alaska Indians and 2,341 among New Mexico Indians. Fifty-four percent of the total cases among Alaska Indians and 53% of New Mexico Indians were diagnosed in women. The most frequently diagnosed cancers among Alaska Indian men were prostate (20% of all cancers), lung (19%), and colorectal cancer (17%) and among New Mexico Indian men, prostate (24%), colorectal (11%), and kidney cancer (8%). Lung cancer accounted for <7% of cancers among New Mexico Indian men. The top three cancers among Alaska Indian women during this time period were breast (37%), colorectal (13%), and lung (11%) and among New Mexico Indian women, breast (24%), colorectal (10%), and uterine (7%) cancer. Lung cancer accounted for 3% of the total cancer among New Mexico women.

Alaska Indian men and women had higher cancer incidence rates for all sites combined than New Mexico Indians or U.S. Whites (Tables 1 and 2 ). Alaska Indian men had more than twice the cancer incidence rate (668 per 100,000) for all sites combined compared with New Mexico Indian men (277 per 100,000). Specific cancer sites, which show an excess of cancer in Alaska Indian men compared with New Mexico Indian men include oral cavity/pharynx (specifically nasopharynx), esophagus, colorectal, pancreas, lung, prostate, urinary bladder, kidney, and non–Hodgkin's lymphoma. Lung and esophageal cancers among Alaska Indian men were more than six times the rate of New Mexico Indian men. Compared with U.S. Whites, Alaska Indians had a higher overall rate of oral cavity/pharynx, esophagus, stomach, colorectal, gallbladder, lung, and kidney cancers. The incidence rates for nasopharyngeal and gallbladder cancer among Alaska Indian men were >10 times the U.S. White rate.


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  		Table 1. Comparisons of average annual age-adjusted cancer incidence rates in Indian men of Alaska and New Mexico and U.S. White men, 1993-2002

 

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  		Table 2. Comparisons of average annual age-adjusted cancer incidence rates in Indian women of Alaska and New Mexico and U.S. White women, 1993-2002

 
Among Alaska Indian women, rates for many cancers were significantly higher than rates in New Mexico Indian and U.S. White women. Rates for all sites combined among Alaska Indian women were more than double those of New Mexico Indian women and one and a half times the U.S. White overall rate. Alaska Indian lung cancer rates were 10 times the rate among New Mexico Indian women and one and a half times the U.S. White rate. Other sites for which Alaska Indian women exceeded rates in New Mexico Indian women include oral cavity/pharynx, colorectal, lung, melanoma, breast, and multiple myeloma. Differences in women's rates of cancer among Alaska Indians and U.S. Whites for specific sites were found for oral cavity/pharynx, stomach, colorectal, liver, gallbladder, lung, breast, kidney, and multiple myeloma. Stomach, liver, and gallbladder cancer incidence in Alaska Indian women was three or more times that of U.S. Whites.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
National cancer incidence rates for American Indians and Alaska Natives combined may hide important differences in cancer incidence between culturally and geographically diverse population groups. The ~2-fold higher incidence of all cancers among Alaska Indians compared with Indians of New Mexico is largely due to cancers associated with tobacco use, including cancers of the oral cavity/pharynx, esophagus, colorectal, pancreas, larynx, lung, prostate, and urinary bladder. The greatest difference exists for lung cancer, in which Alaska Indian men and women have five and seven times the rate of lung cancer, respectively, compared with New Mexico Indian men and women.

Data from the National Center for Chronic Disease Prevention and Health Promotion Behavioral Risk Factor Surveillance System telephone surveys document that current smoking rates, use of other types of tobacco, and quit rates for all Alaska Natives (including Eskimo and Aleut people) and New Mexico Indians are strikingly different. Surveys conducted during the years 1997 to 2000 in 36 states indicate that Native Americans, 18 years of age and older, from southwestern states (Arizona, Colorado, Nevada, New Mexico, and Utah) have the lowest prevalence rate of current smokers (21%), whereas Alaska Natives show one of the highest smoking rates (39%) among American Indian and Alaska Native adults of 5 U.S. geographic regions surveyed (14). Behavioral Risk Factor Surveillance System surveys for the years 1988 to 1992 show a higher use of smokeless tobacco among all Alaska Natives combined than Indians of the southwest United States (11% versus 6%, respectively) and lower rates of quitting smoking (37% versus 51%; ref. 15). Other tobacco-associated cancers of oral cavity/pharynx, esophagus, and urinary bladder showed greater incidence rates among Alaska Indians compared with New Mexico Indians.

Alaska Indians have a 3-fold greater incidence of colorectal cancer compared with New Mexico. Increased risk for colorectal cancer has been associated with inflammatory bowel disease, family history of colorectal cancer, obesity, alcohol consumption, diets high in fats and low in dietary fiber (16), and diabetes (17) and more recently associated with smoking (18, 19). Studies of Alaska Native diets over the past 30 years reveal a profile not different from the current average American diet, one of high animal meat and fat consumption (20). A nationwide 2002 Behavioral Risk Factor Surveillance System survey showed that 78% of all Alaska Natives and 75% of both New Mexico Indians and U.S. Whites reported eating fewer than the five recommended servings of fruit and vegetables everyday (21). Low intakes of fruits, vegetables, and dietary fiber in rural Alaska, where access to certain foods may be limited by season and/or high cost, may be an important contributor to the high rates of colorectal cancer found among Alaska Native people (22, 23). Dietary studies indicate a high consumption of fish among Alaska Natives, but longitudinal studies are needed to determine the benefits to cancer prevention (24, 25). Other potential risks for colorectal cancer include obesity and inactivity. In the same 2002 Behavioral Risk Factor Surveillance System survey, 36% of Alaska Natives, 25% of New Mexico American Indians, and 25% of the total U.S. population reported "no leisure time physical activity". In addition, in the 2002 survey, the proportion of all American Indian/Alaska Native adults overweight or obese was shown to be 64% compared with the U.S. total population of 59%. Sixty-nine percent of Alaska Natives and 67% of New Mexico Indians were defined as overweight or obese based on reported height and weight (21).

Prostate cancer accounts for 20% of all cancers among Alaska Indian men and 24% among New Mexico Indian men. Prostate cancer rates for both Native groups are currently lower than rates among U.S. Whites but seem to be increasing (5, 26). Alaska Indian rates are twice that of New Mexico Indian prostate cancer rates. Population-based studies have suggested that diets high in certain fats may increase the risk of prostate cancer (27), whereas diets high in fats obtained from fish have been associated with lower rates of prostate cancer (24, 27). Although Alaska Indians, particularly those living in coastal regions and along waterways of Alaska, have access to fish, the benefit to reducing risk of prostate cancer is not known.

Breast cancer comprises one third of all cancers among Alaska Indian women and one fourth of cancer among New Mexico Indian women. For many years, breast cancer incidence among all Alaska Native women combined was significantly lower than in U.S. White women, but the rate among Alaska Indians exceeds that of U.S. Whites. Rates of breast cancer among New Mexico Indians have remained lower than New Mexico Whites (Hispanic and non-Hispanic) as well as U.S. Whites (28), whereas rates of breast cancer among Alaska Indians are 4-fold higher. Screening for breast cancer has increased among Alaska Natives and may account for some of the increase in the number of incidence cases; however, breast cancer mortality has tripled since 1969 (29). Risk factors for breast cancer include a family history of breast cancer, early age of onset of menstruation, late onset of menopause, no children or childbirth after age 30, heavy alcohol use, no regular exercise, and overweight (30). These factors have not been well explored in Alaska and New Mexico Indian women. A higher proportion of Alaska Natives (36%) reported inactivity in the Behavioral Risk Factor Surveillance System surveys than New Mexico Indians (25%), but it is doubtful that this alone would account for the severalfold higher rate of breast cancer among Alaska Indian women compared with New Mexico Indians.

Nasopharyngeal cancer occurs rarely among New Mexico Indians and in the U.S. White population. The rate in Alaska Indians is 6-fold higher among men and 13-fold higher among women compared with U.S. Whites. Studies of nasopharyngeal cancer among Alaska Natives indicate a strong association with EBV infection (31, 32). In parts of Asia and Northern Africa where nasopharyngeal cancer is common, increased risk has been associated with diets high in salt-cured fish and meat in conjunction with EBV (33).

Stomach cancer was two to three times higher in Alaska Indians than in U.S. Whites and about one and a half times higher than New Mexico Indians. Increased risk of stomach cancer has been linked to a variety of lifestyle and environmental factors, including food preservation, diets high in fat, obesity, and decreased consumption of foods containing dietary fiber, vitamin C, beta-carotene, and folate (34). However, Helicobacter pylori, a relatively common bacterial infection of the stomach, is an important risk factor for stomach cancer (35, 36). Alaska Native people have been reported to have a high prevalence of H. pylori infection. In a retrospective study of serum samples from 2,080 healthy Alaska Natives, 75% of the samples were found to be positive for H. pylori (37). The prevalence of H. pylori in New Mexico Indians has not been reported; however, prevalence of H. pylori infection in the U.S. population has been estimated to be in the range of 40% to 50% (38).

Liver cancer occurs at a significantly higher rate in Alaska and New Mexico Indians compared with U.S. Whites. The elevated rate in New Mexico Indians is particularly noteworthy, given their low incidence of cancer overall. Hepatitis B and C have accounted for a large portion of liver cancer worldwide (39). In the early 1980s, Alaska Natives had the highest rate of chronic hepatitis B infection (8%) and the highest rate of liver cancer among all racial/ethnic groups of the United States (40). Serosurveys for identifying hepatitis B infection conducted between 1983 to 1987 among >52,000 Alaska Natives resulted in >13%, showing evidence of current, prior, or chronic infection (41). The frequency of new hepatitis B infections declined considerably among Alaska Natives following a statewide immunization program begun in 1982 (42). Declines in hepatocellular carcinomas among children occurred following the 1982 program among Alaska Native children (43). Synergistic effects of viral hepatitis infection, heavy alcohol consumption, and diabetes greatly increase risk (44, 45).

New Mexico and Alaska Indians have high rates of gallbladder cancer. Risk factors for gallbladder cancer include chronic gallstones and inflammation of the gallbladder, smoking, obesity, a diet high in carbohydrates and low in fiber, and persons of Native American and Mexican descent (46). Prior studies in New Mexico Indians have shown a high prevalence of gallbladder disease, including gallstones (47, 48).

Although many types of cancer occur at a higher rate in Alaska and New Mexico Indians compared with U.S. Whites, there are also a variety of cancers that occur at lower rates. These cancers include leukemia, melanoma, urinary bladder, and brain cancers.

In conclusion, we have studied cancer patterns in two racially similar populations (Alaska and New Mexico Indians) living in two markedly different geographic regions among whom there is good case ascertainment of incident cancers. Rates of these populations were compared with each other and to U.S. Whites. This study documents several important findings: (a) marked differences in cancer rates for selective cancer sites between Alaska and New Mexico Indians, (b) disparities (excesses) in cancers among Alaska Indians compared with U.S. Whites for all cancers combined, (c) disparities among Alaska Indians for selective cancer sites over and above the general high rate of cancer, (d) high rates for selective cancer sites among New Mexico Indians despite overall low rates, and (e) low rates for selective cancers among both Alaska and New Mexico Indians compared with U.S. Whites. The known relationship of cancer and tobacco and the marked difference in tobacco use among Alaska and New Mexico Indians would seem to explain some, but not all, of the differences in cancer rates. This study emphasizes the importance of having population-specific incidence data in contrast to aggregate data on special populations. Further study of cancer sites, which are particularly high (or low) in these populations, and risk factor comparisons may provide additional clues to cancer etiology.


   Acknowledgments
 
We thank the tumor registrars, medical record personnel, and many others throughout the states of Alaska and New Mexico who helped assure the completeness and accuracy of these data.


   Footnotes
 
Grant support: Interagency Agreement grant 9 UBI 94 00003-04 with the National Cancer Institute.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

Received 6/20/05; revised 5/25/06; accepted 6/ 5/06.


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