Annual Report to the Nation on the Status of Cancer 1975-2004, Featuring Cancer in American Indians and Alaska Natives: Questions and Answers
- Death rates decreased on average 2.1 percent per year from 2002
to 2004, nearly twice the annual decrease of 1.1 percent per year from
1993 through 2002.
- Declines were observed in the incidence
of lung cancer in men, colorectal cancer in men and women, and in breast
cancer incidence in women from 2001 through 2004.
- Overall, rates for most cancers among American Indians and Alaska Natives (AI/AN) were
lower than non-Hispanic whites from 1999 through 2004, but were higher
for cancers of the stomach, liver, kidney, gallbladder, and cervix.
- Regional analyses revealed high cancer rates for AI/AN in the Northern and Southern
Plains and Alaska (e.g., lung cancer and colorectal cancer).
1. What is the purpose of this report and who created it?
This report provides an update of cancer incidence rates (new cases), death
rates, and trends in the United States as well as an in-depth analysis of a
selected topic. The Centers for Disease Control and Prevention (CDC), the North
American Association of Central Cancer Registries (NAACCR), the American Cancer
Society (ACS), and the National Cancer Institute (NCI), which is part of the
National Institutes of Health, have collaborated annually since 1998 to create
this report. For the report this year, researchers from the Indian Health Service,
the Mayo Clinic College of Medicine, and the New Mexico Tumor Registry also
participated as co-authors in the report.
The feature section of this report describes cancer incidence, stage at diagnosis,
screening, and risk factors by Indian Health Service (IHS) region for American
Indian and Alaska Natives (AI/AN) and compares them with those of non-Hispanic
white (NHW) populations.
2. What are the sources of the data?
Cancer mortality information in the United States is based on causes of death
reported by physicians on death certificates and filed by state vital statistics
offices. The mortality information is processed and consolidated in a national
database by the CDC through the National Vital Statistics System, which covers
the entire United States.
Information on newly diagnosed cancer cases occurring in the United States
is based on data collected by registries in the CDC's National Program of Cancer
Registries (NPCR) and NCI's Surveillance, Epidemiology, and End Results (SEER)
Program. NAACCR evaluates and publishes data annually from registries in both
programs. Incidence rates are for invasive cancers, except for bladder cancer,
which includes in situ cancer (cancer that is confined to the inner
lining of the bladder).
Long-term (1975-2004) trends for all races for all sites combined and for the
15 most common cancers were based on SEER incidence data covering about 10
percent of the U.S. population. Fixed-interval trends (1995-2004) for
specific time periods for five racial/ethnic populations, (white, black, Asian/Pacific
Islander and AI/AN racial groups, and Hispanic/Latino and non-Hispanic ethnic
groups regardless of race) by sex, for all sites combined and for the 15 most
common cancers were based on about 59 percent of the U.S. population. Average
annual (2000-2004), sex-specific, and age-adjusted incidence rates were based
on incidence data from 39 cancer registries, covering about 82 percent of the
3. Which reporting periods were chosen as a main focus of the report?
The period from 2000 through 2004 was used for describing the cancer burden
(1999 through 2004 was chosen for AI/AN), and the period 1995 through 2004
was used for describing trends among the five major racial and ethnic populations.
The period from 1975 through 2004 was chosen to represent the best perspective
on long-term trends in cancer incidence and death rates among all races combined.
4. What is happening with cancer incidence trends overall?
After increasing from 1975 through 1992,
incidence rates for all cancers combined for all sexes and populations combined
decreased slightly from 1992 through 2004. For men, incidence rates for
all cancers decreased by 4.3 percent per year from 1992 through 1995 and were
stable from 1995 through 2004. For women, incidence rates for all cancers combined
stabilized from 1999 through 2004 after years of increases.
While the report did find a decline in cancer incidence of 0.3 percent per
year from 1992 through 2004 in men and women combined, there are several reasons
why this is not emphasized. The annual percent change is small, the trends
are not significant when men and women are viewed separately, and trends in
incidence are much more difficult to interpret than trends in mortality.
Incidence trends are related to screening as well as risk. For instance, an
increase in the utilization of the prostate specific antigen (PSA) test from
1988 to 1992 caused a rapid increase in male cancer incidence rates due to
the detection of asymptomatic prostate cancer, which was then followed by a
In contrast with mortality, where declines are always good news, declines in
incidence may reflect good news (decreases in risk factors that cause cancer
or use of screening tests such as colorectal and pap tests that can actually
prevent cancer) or bad news (decreased use of screening tests) or a combination
of the two.
5. What is happening with incidence rates for the top 15 cancers
among men and women?
Among men, incidence rates of myeloma and cancers of the liver, kidney and
esophagus continued to increase through 2004. Incidence rates are still decreasing
for cancers of the lung, colon and rectum, oral cavity and stomach and
were stable through 2004 for the remaining top 15 cancers (non-Hodgkin lymphoma,
melanoma, leukemia and cancers of the prostate, bladder, pancreas, and brain).
Among women, the rates for non-Hodgkin lymphoma, melanoma, leukemia, and cancers
of the bladder and kidney have been increasing for 29 years. Thyroid cancer
incidence rates have increased in women since 1980. The incidence rates decreased
for cancers of the breast, colon and rectum, uterus, ovary, cervix, oral cavity
and stomach. The incidence rates for cancer of the pancreas and lung were stable.
6. What is happening with cancer mortality trends overall?
The overall decline in cancer death rates for most racial and ethnic populations,
first noticed in the early 1990s, has continued through 2004. Death rates decreased
on average 2.1 percent per year from 2002 through 2004, nearly twice the annual
decrease of 1.1 percent per year from 1993 through 2002. This decline was more
pronounced among men (2.6 percent per year from 2002-2004) than women (1.8
percent per year from 2002-2004). Death rates are the best indicator of progress
7. What is happening with death rates for the top 15 cancers among
men and women?
For the most recent reporting period, which varies by cancer type, death
rates decreased for 12 of the 15 most common causes of cancer death in men
(i.e., cancers of the lung, prostate, colon and rectum, pancreas, bladder,
kidney, stomach, brain, and oral cavity as well as leukemia, non-Hodgkin lymphoma,
and myeloma). Death rates increased for esophageal and liver cancers in men,
but recently stabilized for melanoma.
Death rates among women decreased for 10 of the 15 most common cancers (i.e.,
breast, colon and rectum, stomach, kidney, cervix, brain and bladder cancers
as well as non-Hodgkin lymphoma, leukemia, and myeloma). However, death rates
were stable in women for cancers of the pancreas, ovary, and uterus and continued
to increase for cancers of the liver and lung.
8. What is happening with incidence rates for breast cancer?
Breast cancer incidence rates among women decreased for the period 2001 through
2004 by 3.5 percent per year, reversing a long-term increase that began in
the early 1980s. The factors that influence breast cancer incidence are complex,
including changes in reproductive risks, obesity, and the prevalence
of mammography screening, among others. Recent reports suggest the decrease
in breast cancer incidence may be related to the rapid discontinuation of hormone
replacement therapy, a known risk factor for breast cancer and a decline in
mammography screening prevalence.
9. What is happening with incidence rates for lung cancer?
Overall, lung cancer incidence rates increased in women from 1975 through
1998, after which the rate stabilized. In comparison, the lung cancer incidence
rate in men has been decreasing since 1991. The difference reflects changes
in smoking trends in men and women.
10. If cancer rates continue to fall, does that mean the number of
people dying from cancer will also continue to fall?
Not necessarily. The numbers reported in the Annual Report to the Nation
are rates per 100,000 persons in the U.S. and are adjusted for age so that
they are comparable across various factors, such as race. The actual number
of people dying from cancer (sometimes called the count) can be influenced
by several factors, including the growth in the number of older people in the
U.S. (cancer is primarily a disease of aging) and the increase in size of the
Therefore, while the cancer rate may go down in a given year, if there is
an increase in the size and the overall age of the U.S. population that same
year, the actual count of the number of cancer cases could go up. The
National Center for Health Statistics has already released preliminary numbers
for 2005 that indicate this may be the case when the next Annual Report to
the Nation is issued in 2008.
11. What is the size of the AI/AN population in the United States
and is it changing?
AI/AN populations are among the fastest growing populations in the U.S. According
to the 2000 U.S. Census, 1.1 percent of the population stated they have AI/AN
12. How do cancer incidence rates differ in the AI/AN population
compared to the non-Hispanic white population?
The report finds that for 1999 through 2004, AI/AN persons in all regions
combined had lower incidence rates than non-Hispanic whites (NHW) for most
cancers, but were less likely than the NHW population to be diagnosed with
early stage cancers of the colon and rectum, prostate, female breast, and cervix.
However, AI/AN persons had higher incidence rates for cancers of the stomach,
liver, kidney, gallbladder, and cervix than NHW populations.
13. What are the possible causes of higher cancer incidence rates
in AI/AN populations?
Many types of cancer with higher incidence rates in AI/AN populations are
associated with infections: human papilloma virus (HPV) in cervical cancer; Helicobacter
pylori (H. pylori) bacteria in stomach cancer; and hepatitis
B virus (HBV) and hepatitis C virus (HCV) in liver cancer. Explanations for
these differences vary by cancer type and may include higher infection rates
in the countries of original residence or birth (HPV); chronic infection (HBV
and HCV); sanitary conditions (H. pylori); or varied availability
and use of preventive measures.>
14. What factors affect cancer disparities in AI/AN populations in
comparison with non-Hispanic white populations?
Some factors that may contribute to differences in AI/AN cancer rates include
higher incidence of some infection-related cancers; elevated exposures to environmental
risk factors in AI/AN populations’ living and work places; lower education,
health literacy, and income; reduced use of screening services; limited access
to health care often due to lack of insurance or geographic barriers; and less
information available regarding possible genetic predispositions. Also, this
population experiences unique cultural and language barriers to health services
in addition to the multitude of institutional, environmental, logistical, sociodemographic
and personal barriers characteristic of all minority populations in the U.S.
15. How do AI/AN cancer incidence rates differ by geographic region?
For the purposes of this report, the authors identified six regions in the
U.S. that best represented AI/AN populations. For all cancer types combined,
the report finds that incidence rates in the AI/AN population of the Northern
and Southern Plains and in Alaska are higher than in the AI/AN population in
the Southwest, Pacific Coast and East. For men, AI/AN rates are higher in the
Northern Plains and similar in the remaining regions (Alaska and Southern Plains)
or lower (East, Southwest and Pacific Coast). For leading cancers, there was
substantial regional variation in AI/AN incidence rates. Lung cancer incidence
rates are higher in the Northern Plains, Alaska and the Southern Plains, lower
in the Pacific Coast and the East and lowest in the Southwest. Colorectal cancer
incidence is three or more times greater in Alaska and the Northern Plains
than in the Southwest. Breast cancer is greatest in Alaska Natives and lowest
in the Southwest with intermediate rates in the remaining regions.
16. What are the possible causes for geographic variations in cancer
Several other cancers are elevated in AI/AN populations in certain geographic
regions only. In the case of lung cancer, the elevated rates in Alaska and
the Northern Plains can be easily explained by decades of high prevalence of
cigarette smoking among the AI/AN population of those regions, evidence that
is further strengthened by the very low rates in the Southwest where AI/AN
smoking has historically been very low. The cause of differences in AI/AN regional
colorectal cancer rates is less clear and is likely due to multiple factors
that may include diet, genetic makeup, tobacco use, diabetes, environmental
factors and others.
17. Do AI/AN persons have equal access to quality cancer care?
This study reports less favorable socioeconomic status and health care access
for AI/AN persons compared with NHW populations. Having a usual source of care
is a key predictor of cancer screening and other preventive services, and consistent
with this, cancer screening for AI/AN populations is lower in comparison with
NHW populations; furthermore, this report and previous studies have found that
AI/AN populations are diagnosed more frequently with late-stage disease and
have less favorable cancer survival compared with other populations.
The IHS provides primary health care to approximately 1.8 million enrolled
members of federally-recognized tribes, out of the estimated 3.3 million AI/AN
persons in the U.S. The 150 IHS hospitals and clinics are primarily located
on reservation lands and in a few cities with relatively large AI/AN populations.
Half of these health care facilities are managed by tribal governments under
negotiated agreements with the U.S. federal government, and half are operated
directly by the federal government. An additional 34 urban health centers receive
some federal funding to provide health care to urban AI/AN individuals. Eligible
AI/AN persons can receive free health care at any IHS facility, but a complex
set of rules governs and restricts delivery of contract health services for
specialty medical care, such as cancer treatment, which is generally not available
in IHS facilities. Geographic, financial, and bureaucratic barriers to receiving
appropriate cancer treatment as well as cultural beliefs may also contribute
to poor survival rates among AI/AN persons.
18. How are cancer disparity issues being addressed for AI/AN communities?
Health disparities among U.S. populations are a focus of increased research
and interventions. The following organizations and initiatives are seeking to bridge cancer disparity
issues in AI/AN communities:
- The CDC’s National Breast and Cervical Cancer Early Detection Program
funds 14 tribal programs, in addition to all 50 states, to build and support
infrastructure and provide screening services.
- The IHS and CDC provide
annual training for primary care providers in IHS and tribal programs to perform
colposcopy, part of standard diagnostic follow-up for abnormal Pap smear results,
to make this service more accessible and to reduce the time from abnormal cervical
cancer screening results to definitive diagnosis.
- The CDC’s National
Comprehensive Cancer Control Program (http://www.cdc.gov/cancer/ncccp/).
This program has helped address cancer disparities by supporting cancer control
coalitions in each state to develop and implement cancer control plans in communities,
including tribal communities, across the U.S.
- Circle of Life is an ACS
program designed to decrease the breast cancer incidence and death rates among
American Indian women. Working with available community resources, Circle of
Life develops effective, culturally sensitive strategies to increase public awareness
of the disease while also promoting the use of mammography as an early detection
- The ACS's Research Targeted at Poor and Underserved Populations
Initiative, through a competitive peer-reviewed mechanism, funds research grants
that serve to reduce the burden of cancer in underserved populations, including
Native Americans. Since 2004, four research grants have been awarded totaling
$3.5 million. Two seminal studies, conducted in full collaboration and partnership
with the Apsaalooke tribe, using Community-Based Participatory Research methods,
focus on promoting cervical cancer screening using Lay Health Advisors (members
of the tribe), as well as promoting systemic change by enhancing cultural sensitivity
in the IHS. A third study focuses on smoking cessation strategies specifically
tailored to Native American populations, and the fourth study on ways to relieve
cancer pain in Native Americans in Arizona.
- The NCI Network for Cancer
Control Research Among AI/AN Populations is a forum for Native and non-Native
researchers with a mission to “reduce preventable cancer morbidity and
mortality to the lowest possible levels and to improve cancer survival to the
highest possible level” in AI/AN populations. Realizing the importance
of AI/AN community participation in research, the Network also provides curriculum
development and instructors for an annual cancer control training course for
Native researchers. NCI is an important partner in promoting and funding community
networks programs such as the Spirit of Eagles program.
- The Spirit of
Eagles program, based at the Mayo Clinic in Rochester, Minn., is a national AI/AN
leadership initiative addressing comprehensive cancer control through tribal
partnerships. Funded by the NCI’s Center to Reduce Cancer Health Disparities,
the SOW works with major cancer centers, nonprofit organizations, policy boards,
professional societies, and educators through community-based cancer control
grants. NCI has funded three other regional or local community networks working
with AI/AN populations in the Pacific Northwest, the Southwest and Oklahoma.
NCI Cancer Information Service collaborates with community networks to reach
medically underserved audiences and partners with researchers to develop messages,
channels, and strategies for communicating risk and early detection approaches
for AI/AN populations. In addition, NCI has initiated the Patient Navigator Research
Program to assist patients who receive an abnormal screening result get a definitive
diagnosis, and, finally, proper treatment.
19. How are cancer incidence and death rates presented?
Cancer incidence rates and death rates are measured as the number of cases
or deaths per 100,000 people per year and are age-adjusted to the 2000 U.S.
standard population. When a cancer affects only one sex -- for example, prostate
cancer -- then the number is per 100,000 persons of that sex. The numbers are
age-adjusted, which allows for comparison of rates from different populations
with varying age composition over time and regions.
20. What is annual percent change or APC
The annual percent change (APC) is the average rate of change in a cancer
rate per year in a given time frame (i.e., how fast or slowly a cancer rate
has increased or decreased each year over a period of years). Annual percent
change was calculated for both incidence and death rates. The number is given
as a percent, such as an approximate one percent per year decrease.
A negative APC describes a decreasing trend, and a positive APC describes an
increasing trend. In this report, trends are reported as increasing and decreasing
only if they are statistically significant.
21. What are rate ratios and why were they used in a Report to the
Rate ratios (RR) allow comparison of incidence rates between AI/AN and NHW
populations. In describing rate comparisons for AI/AN and NHW populations,
the terms, “higher” or “lower” were used when the AI/AN
incidence rates were statistically significantly higher or lower than the NHW
rates. Thus, when the RR was less than 1.0, the rate among AI/AN was lower
than that among NHW; when the RR was greater than 1.0, the rate among AI/AN
was higher than that among NHW. Otherwise, the RRs were described as comparable.
22. Why were rates adjusted for delays in reporting incidence data
This report presents analyses of long-term trends in cancer incidence rates
with and without adjustment for reporting delays and more complete information.
Adjusting for these delays and accumulating more complete and accurate information
provides the basis for a potentially more definitive assessment of incidence
rates and trends in the most recent years for which data are available. Cancer
registries routinely take two to three years to compile their current cancer
statistics. An additional one to two years may be required to have more complete
incidence data on certain cancers, such as melanoma and prostate and breast
cancers, particularly when they are diagnosed in outpatient settings. Cancer
registries continue to update incidence rates to include these cases. Consequently,
the initial data reported for certain cancer incidence rates may be an underestimate.
Long-term reporting patterns in SEER registries have been analyzed, and it
is now possible to adjust site-specific incidence rates and incidence rates
for all cancers combined to correct for expected reporting delays and more
23. What is joinpoint analysis and how does it account for the different
time periods used for trends analysis in this report?
Joinpoint analysis is a statistical method that describes changing trends
over successive segments of time and the amount of increase or decrease within
each segment. This statistical method chooses the best-fitting point or points,
which are called joinpoints; these points are where the rate of increase or
decrease changes significantly.
Joinpoint regression analysis involves fitting a series of joined straight
lines to the age-adjusted rates, and each line segment is described by an annual
percent change that is based on the slope of the line segment. Each joinpoint
denotes a statistically significant change in trend. Thus, for death
rates for all cancers combined in men, the slope, or trend, changes in 2002
and is reported as a 2.6 percent per year decline from 2002 through 2004. For
women, the trend also changes in 2002 and is reported as a 1.8 percent per
year decline from 2002 through 2004 in this report.
Joinpoint analyses were performed for incidence and mortality trends for 1975
24. Where is this report published?
The report appeared online on October 15, 2007 at www.interscience.wiley.com/cancer/report2007 and
will appear in the November 15, 2007 print edition of Cancer.
25. Where can I find out more about the report?
For more information, visit the following Web sites:
‘Annual Report to the Nation’ press release: http://cancer.gov/newscenter/pressreleases/ReportNation2007Release
For supplemental material, please go to www.interscience.wiley.com/cancer/report2007
CDC (Division of Cancer Prevention and Control): http://www.cdc.gov/cancer
CDC (National Center for Health Statistics’ mortality report): http://www.cdc.gov/nchs/deaths.htm
NCI: http://www.cancer.gov and the SEER
Homepage: http://www.seer.cancer.gov . Click
on the icon "1975-2004 Report to the Nation."
Citation: Espey DK, Wu X, Swan J, Wiggins C, Jim M, Ward E, Wingo PA, Howe
HL, Ries LAG, Miller BA, Jemal A, Ahmed F, Cobb N, Kaur JS, Edwards BK. Annual
Report to the Nation on the Status of Cancer, 1975-2004, Featuring Cancer in
American Indians and Alaska Natives. Cancer. November 15, 2007. Vol.
110, Issue 10.
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