David K. Espey

Annual report to the nation on the status of cancer, 1975–2004, featuring cancer in American Indians and Alaska Natives

The American Cancer Society, the Centers for Disease Control and Prevention, the National Cancer Institute, and the North American Association of Central Cancer Registries collaborate annually to provide updated information on cancer occurrence and trends in the U.S. The 2007 report features a comprehensive compilation of cancer information for American Indians and Alaska Natives (AI/AN).

Regional patterns and trends in cancer mortality among American Indians and Alaska Natives, 1990–2001†

National estimates of cancer mortality indicate relatively low rates for American Indians (AIs) and Alaska Natives (ANs). However, these rates are derived from state vital records in which racial misclassification is known to exist.

Cancer among American Indians and Alaska Natives in the United States, 1999–2004

Cancer incidence rates vary among American Indian and Alaska Native (AI/AN) populations and often differ from rates among non‐Hispanic whites (NHWs). However, the misclassification of race for AI/AN cancer cases in central cancer registries may have led to underestimates of the AI/AN cancer burden in previous reports.

Methods for improving cancer surveillance data in American Indian and Alaska Native populations.

The misclassification of race decreases the accuracy of cancer incidence data for American Indians and Alaska Natives (AI/ANs) in some central cancer registries. This article describes the data sources and methods that were used to address this misclassification and to produce the cancer statistics used by most of the articles in this supplement.

Leading Causes of Death and All-Cause Mortality in American Indians and Alaska Natives

OBJECTIVES We present regional patterns and trends in all-cause mortality and leading causes of death in American Indians and Alaska Natives (AI/ANs). METHODS US National Death Index records were linked with Indian Health Service (IHS) registration records to identify AI/AN deaths misclassified as non-AI/AN. We analyzed temporal trends for 1990 to 2009 and comparisons between non-Hispanic AI/AN and non-Hispanic White persons by geographic region for 1999 to 2009. Results focus on IHS Contract Health Service Delivery Area counties in which less race misclassification occurs. RESULTS From 1990 to 2009 AI/AN persons did not experience the significant decreases in all-cause mortality seen for Whites. For 1999 to 2009 the all-cause death rate in CHSDA counties for AI/AN persons was 46% more than that for Whites. Death rates for AI/AN persons varied as much as 50% among regions. Except for heart disease and cancer, subsequent ranking of specific causes of death differed considerably between AI/AN and White persons. CONCLUSIONS AI/AN populations continue to experience much higher death rates than Whites. Patterns of mortality are strongly influenced by the high incidence of diabetes, smoking prevalence, problem drinking, and social determinants. Much of the observed excess mortality can be addressed through known public health interventions.

Health Behaviors and Risk Factors Among American Indians and Alaska Natives, 2000–2010

OBJECTIVES We provided contextual risk factor information for a special supplement on causes of death among American Indians and Alaska Natives (AI/ANs). We analyzed 11 years of Behavioral Risk Factor Surveillance System (BRFSS) data for AI/AN respondents in the United States. METHODS We combined BRFSS data from 2000 to 2010 to determine the prevalence of selected risk factors for AI/AN and White respondents residing in Indian Health Service Contract Health Service Delivery Area counties. Regional prevalence estimates for AI/AN respondents were compared with the estimates for White respondents for all regions combined; respondents of Hispanic origin were excluded. RESULTS With some regional exceptions, AI/AN people had high prevalence estimates of tobacco use, obesity, and physical inactivity, and low prevalence estimates of fruit and vegetable consumption, cancer screening, and seatbelt use. CONCLUSIONS These behavioral risk factors were consistent with observed patterns of mortality and chronic disease among AI/AN persons. All are amenable to public health intervention.

Disparities in Cancer Mortality and Incidence Among American Indians and Alaska Natives in the United States

OBJECTIVES We used improved data on American Indian and Alaska Native (AI/AN) ancestry to provide an updated and comprehensive description of cancer mortality and incidence among AI/AN populations from 1990 to 2009. METHODS We linked the National Death Index and central cancer registry records independently to the Indian Health Service (IHS) patient registration database to improve identification of AI/AN persons in cancer mortality and incidence data, respectively. Analyses were restricted to non-Hispanic persons residing in Contract Health Service Delivery Area counties in 6 geographic regions of the United States. We compared age-adjusted mortality and incidence rates for AI/AN populations with White populations using rate ratios and mortality-to-incidence ratios. Trends were described using joinpoint analysis. RESULTS Cancer mortality and incidence rates for AI/AN persons compared with Whites varied by region and type of cancer. Trends in death rates showed that greater progress in cancer control was achieved for White populations compared with AI/AN populations over the last 2 decades. CONCLUSIONS Spatial variations in mortality and incidence by type of cancer demonstrated both persistent and emerging challenges for cancer control in AI/AN populations.

Methods for Improving the Quality and Completeness of Mortality Data for American Indians and Alaska Natives

OBJECTIVES We describe methods used to mitigate the effect of race misclassification in mortality records and the data sets used to improve mortality estimates for American Indians and Alaska Natives (AI/ANs). METHODS We linked US National Death Index (NDI) records with Indian Health Service (IHS) registration records to identify AI/AN deaths misclassified as non-AI/AN deaths. Analyses excluded decedents of Hispanic origin and focused on Contract Health Service Delivery Area (CHSDA) counties. We compared death rates for AI/AN persons and Whites across 6 US regions. RESULTS IHS registration records merged to 176,137 NDI records. Misclassification of AI/AN race in mortality data ranged from 6.3% in the Southwest to 35.6% in the Southern Plains. From 1999 to 2009, the all-cause death rate in CHSDA counties for AI/AN persons varied by geographic region and was 46% greater than that for Whites. Analyses for CHSDA counties resulted in higher death rates for AI/AN persons than in all counties combined. CONCLUSIONS Improving race classification among AI/AN decedents strengthens AI/AN mortality data, and analyzing deaths by geographic region can aid in planning, implementation, and evaluation of efforts to reduce health disparities in this population.

The last frontier: innovative efforts to reduce colorectal cancer disparities among the remote Alaska Native population

BACKGROUND The Alaska Native (AN) population experiences twice the incidence and mortality of colorectal cancer (CRC) as does the U.S. white population. CRC screening allows early detection and prevention of cancer. OBJECTIVE We describe pilot projects conducted from 2005 to 2010 to increase CRC screening rates among AN populations living in rural and remote Alaska. DESIGN Projects included training rural mid-level providers in flexible sigmoidoscopy, provision of itinerant endoscopy services at rural tribal health facilities, the creation and use of a CRC first-degree relative database to identify and screen individuals at increased risk, and support and implementation of screening navigator services. SETTING Alaska Tribal Health System. PATIENTS AN population. INTERVENTIONS Itinerant endoscopy, patient navigation. MAIN OUTCOME MEASUREMENTS AN patients screened for CRC, colonoscopy quality measures. RESULTS As a result of these ongoing efforts, statewide AN CRC screening rates increased from 29% in 2000 to 41% in 2005 before the initiation of these projects and increased to 55% in 2010. The provision of itinerant CRC screening clinics increased rural screening rates, as did outreach to average-risk and increased-risk (family history) ANs by patient navigators. However, health care system barriers were identified as major obstacles to screening completion, even in the presence of dedicated patient navigators. LIMITATIONS Continuing challenges include geography, limited health system capacity, high staff turnover, and difficulty getting patients to screening appointments. CONCLUSIONS The projects described here aimed to increase CRC screening rates in an innovative and sustainable fashion. The issues and solutions described may provide insight for others working to increase screening rates among geographically dispersed and diverse populations.

Regional differences in cervical cancer incidence among American Indians and Alaska Natives, 1999–2004†‡§

Reports from limited geographic regions indicate higher rates of cervical cancer incidence in American Indian and Alaska Native (AI/AN) women than in women of other races. However, accurate determinations of cervical cancer incidence in AI/AN women have been hampered by racial misclassification in central cancer registries.