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Cancer Facts Pain and Cancer

WHO WE ARE

e are among the over 50 million Americans suffering from persistent pain, or the 25 million experiencing acute pain as a result of injury or surgery.(1) One-quarter of us (26%) have had a problem with pain of some sort that has persisted more than 24 hours. An estimated one in five American adults, or about 42 million people, report that pain or physical discomfort disrupts their sleep a few nights a week or more.(2) Further, more than half of all terminally ill patients experience pain in the last days of their lives.(3) In fact, pain affects more Americans than diabetes, cancer, and heart disease combined. The annual cost of chronic

pain in the United States, including healthcare expenses, lost income, and lost productivity, is estimated to be $100 billion.(4) More specifically, we are among the more than 1 million individuals diagnosed with cancer each year and among the 9 million Americans that are cancer survivors.(5) About one in three, and more than 70% of us with advanced cancers experience pain, yet less than half of us receive adequate pain treatment.(6,7) While acute pain is usually the result of illness or injury and has a beginning and endpoint, persistent pain lasts beyond the usual recovery period for an illness or injury. It is often intractable, that is, its cause

Causes/Etiology ●

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African American/black and Hispanic/Latino patients with severe pain are less likely than non-Hispanic/Latino white patients to be able to obtain commonly prescribed pain medicines, because pharmacies in non-white communities do not carry adequate stocks of opioids.(10) A study of 281 Hispanic/Latino and non-Hispanic/Latino white outpatients with recurrent or metastatic cancer showed that 65% of the patients with pain did not receive analgesic medication as recommended by World Health Organization guidelines.(11)

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The percentage of patients with inadequate pain treatment is significantly higher in community clinical oncology programs that treat predominantly African American/black and Hispanic/ Latino patients than in other settings. Thus, pain treatment among minorities is also influenced by the type of treatment facility.(12)

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Two factors that increase the risk of under-management of cancer pain are 1) administration of treatment at institutions that serve primarily African American/black and Hispanic/ Latino patients and 2) a patient-physician discrepancy in the estimate of pain severity.(12)

cannot be treated or removed. As such, it is the number one cause of adult disability in the United States.(8) Persistent pain affects nearly every aspect of our daily life as well as that of our families because of its economic and social consequences. Although most pain can be managed or greatly eased with proper pain management, the tragedy is that most of our pain goes untreated, under-treated, or improperly treated. In fact, 65% of minority patients with pain (compared to 30% of nonminority patients) do not receive the World Health Organization’s recommended analgesics for pain.(9)

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Differences in treatment patterns, pain management, and the use of hospice care exist between African American/black women and women in other ethnic groups.(13)

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Although pain medications are effective in treating cancer pain in more than 80% of patients, many people (32%) do not realize that it is unnecessary for patients to endure inadequately controlled cancer pain.(14)

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Anderson et al. report that 28% of Hispanics/Latinos and 31% of African American/blacks with metastatic or recurrent cancer receive analgesics of insufficient strength to manage their pain.(15)

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More than 80% of African American/black and Hispanic/Latino cancer patients wait until their pain severity is a 10 on a 10-point scale before calling their health care provider or oncology clinic for assistance with pain management.(16)

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Few minority patients are told in advance about the possible side effects of pain medicines or how to manage them.(16)

Project Director Nicholas K. Iammarino, PhD, CHES This ICC Fact Sheet was created through an educational grant from Purdue Pharma L.P.

Research Assistants Mohammed Ansar Ahmed Prem Ramkumar

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Patients who are less educated or who have lower incomes are significantly more likely to hold beliefs that may be barriers to effective pain management.(16)

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Over 40% of Hispanic/Latino and 30% of African American/black patients report they do not take analgesic medications as prescribed by their physician.(16)

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Weisse et al. report that pain treatment decisions do not always vary by patient gender or race despite extensive literature suggesting that women and minorities are treated less aggressively for pain. They suggest that their findings may reflect decreasing disparities perhaps due to increased physician awareness and media coverage of these issues.(17)

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Attitudes and cultural beliefs about coping with pain may explain why Asian American patients are less likely to request an opioid or cease its use prematurely even when there is some pain relief.(18,19)

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Physicians often do not understand a patient’s expression of his or her pain symptoms because of language barriers, low health literacy, and lack of education.(16, 20)

Disparities ●

Studies report that minorities are significantly less likely than non-Hispanic/Latino white patients to receive prescriptions for analgesic agents. They are also at risk for inadequate pain control and under-treatment of pain, and that unrelieved pain among minority groups is highly prevalent.(10, 12, 26)

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African American/black and Hispanic/Latino cancer patients are more likely than non-minority cancer patients to report a need for stronger pain medication and take more of their current analgesic medication than prescribed.(13)

Screening ●

African American/black and Hispanic/Latino cancer patients do discuss their pain with their physicians. However, the majority of African American/black patients and more than one-third of Hispanic patients indicate that they have to bring up the issue of pain management.(11)

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Racial and ethnic differences exist when comparing the effects on pharmacokinetics between Asian Americans and non-Hispanic/Latino whites. However, only a limited number of studies compare differences between African American/blacks and non-Hispanic/Latino whites.(13, 18)

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Accurate appraisal of pain and pain interference may be more difficult for patients who are not of the same gender or ethnic background as the treating physicians.(15)

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Although health care providers recognize that poor pain assessment is a major barrier to optimal pain treatment, they often underestimate pain severity in African American/black and Hispanic/Latino cancer patients.(21)

As reported by Anderson et al., 25% of African American/ black and 12% of Hispanic/Latino patients have received an analgesic prescription they have never filled, while 42% of African American/black and 18% of Hispanic/Latino patients admitted they had filled a prescription for pain medication but had not taken it.(16)

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The meaning of cancer-related pain differs somewhat between African American/black and Hispanic/Latino cancer patients. Hispanic/Latino patients are more likely to describe pain as “suffering,” whereas African American/black patients describe it as “hurt.” When defining what pain means to them, Hispanic/Latino patients tend to focus more on the emotional component of pain, whereas African American/ black patients talk more about the sensory component.(16)

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African American/blacks with chronic illness use more pain coping techniques that employ distraction, praying, or hoping, while non-Hispanic/Latino whites use more pain techniques that involve ignoring pain.(18)

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Minority patients are more likely to have their pain underestimated by providers and less likely to have pain scores documented in their medical record compared to nonHispanic/Latino whites.(22)

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A patient’s ethnicity has a greater impact on the amount of opioid prescribed by the clinician than on the amount of opioid self-administered by their patient.(23)

Pain and Cancer

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Minority patients, including African American/blacks, Hispanics/Latinos, and underserved patients of lower socioeconomic status are at risk for the development of pain that often is associated with metastatic or recurrent disease.(21)

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In a study of women who experienced treatment for breast cancer, African American/black women and Latinas reported increased rates of pain and increased numbers of symptoms.(24)

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Research in cultural quality of life issues, including pain symptom management, has been neglected. Most pain literature acknowledges that culture influences cancer pain management, yet little empirical work has been conducted in this area.(25)

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Religion and faith are important ways in which Hispanic/Latino patients cope with cancer and pain.(26)

Outcomes ●

Metastatic cancer patients at centers that treat predominantly minorities are three times more likely than those treated elsewhere to have inadequate pain management.(12)

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African American/black pain sufferers see themselves as more functionally disabled relative to non-Hispanic/Latino respondents as reflected in their ratings of pain’s interference with common activities of daily living.(15)

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African American/black and Hispanic/Latino patients are less likely to have their pain recorded compared to nonHispanic/Latino whites.(22)

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Although many patients receiving therapy for cancer and advanced malignancies receive “inadequate palliative therapy,” the problem is more severe for minorities than for the average patient.(27)

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Minority patients are more likely to have negative pain management index (PMI) scored compared to nonHispanic/Latino whites.(28)

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Minority patients with cancer in nursing homes are more likely not to have received any analgesic medication.(22, 28)

Pain and Cancer

References 1.

American Pain Foundation. Available at: http://www.painfoundation.org/. Accessed January 2011. 2. National Sleep Foundation. Sleep in America Poll. 2010. Available at: http://www.sleepfoundation.org/sites/ default/files/nsaw/NSF%20Sleep%20in%20%20America%2 0Poll%20-%20Summary%20of%20Findings%20.pdf. Accessed January 2011. 3. Weiss SC, Emanuel LL, Fairclough DL, Emanuel, EJ. Understanding the Experience of Pain in Terminally Ill Patients. Lancet. 2001;357: 1311-15. 4. National Institutes of Health. NIH Guide: New Directions in Pain Research I. September 4, 1998. Available at: http://grants.nih.gov/grants/guide/pa-files/PA-98102.html. Accessed January 2011. 5. Alliance of State Pain Initiatives. Update 2010. Available at: http://aspi.wisc.edu/. Accessed January 2011. 6. Cleeland C, Gonin R, Hatfield A, et al. Pain and Its Treatment in Outpatients with Metastatic Cancer. N Engl J Med. 1994;330: 592-96. 7. Wolfe J, Grier HE, Klar N, et al. Symptoms and Suffering at the End of Life in Children with Cancer. N Engl J Med. 2000; 342(5):326-33. 8. American Chronic Pain Association. Available at: http://www.theacpa.org/default.aspx. Accessed January 2011. 9. WHO Normative Guidelines on Pain Management. Geneva June 2007. Available at: http://www.who.int/medicines/areas/quality_safety/delphi _study_pain_guidelines.pdf. Accessed January 2011. 10. Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL. “We Don’t Carry That” Failure of Pharmacies in Predominantly Nonwhite Neighborhoods to Stock Opioid Analgesics. N Engl J Med. 2001;342(14):1023-26. 11. Cleeland C, Gonin R, Baez L, Loehrer P, Pandya K. Pain and Treatment of Pain in Minority Patients with Cancer: The Eastern Cooperative Oncology Group Minority Outpatient Pain Study. Ann Intern Med. 1997;127(9):813-16. 12. Green CR, Anderson KO, Baker TA, et al. The Unequal Burden of Pain: Confronting Racial and Ethnic Disparities in Pain. Pain Med. 2003;4(3):277-94.

13. Payne R, Medina E, Hampton J. Quality of Life Concerns in Patients with Breast Cancer: Evidence for Disparity of Outcomes and Experiences in Pain Management and Palliative Care among African-American Women. Cancer. 2003;97(1):311-17. 14. Gansler T, Henley SJ, Stein K, Nehl EJ, Smigal C, Slaughter E. Sociodemographic Determinants of Cancer Treatment Health Literacy. Cancer. 2005;104(3):653-660. 15. Anderson K, Mendoza T, Valero V, et al. Minority Cancer Patients and Their Providers: Pain Management Attitudes and Practices. Cancer. 2000;88(8):1929-38. 16. Anderson K, Richman S, Hurley J, et al. Cancer Pain Management among Underserved Minority Outpatients: Perceived Needs and Barriers to Optimal Control. Cancer. 2002;94(8):2295-2304. 17. Weisse CS, Sorum PC, Dominguez RE. The Influence of Gender and Race on Physicians’ Pain Management Decisions. J Pain. 2003;4(9):505-10. 18. Lasch KE. International Association for the Study of Pain. Pain Clinical Updates. Culture and Pain. 2002;10(5). 19. Im EO, Liu Y, Kim YH, Chee W. Asian American Cancer Patients’ Pain Experience. Cancer Nurs. 2008;31(3):E17-23. 20. Cooper-Patrick L, Gallo J, Gonzales J, et al. Race, Gender, and Partnership in the Patient-Physician Relationship. JAMA. 1999;2(6):583-89. 21. Ruehlman LS, Karoly P, Newton C. Comparing the Experiential and Psychosocial Dimensions of Chronic Pain in African Americans and Caucasians: Findings from a National Community Sample. Pain Med. 2005;6(1):49-60. 22. Cintron A. Morrison RS. Pain and Ethnicity in the United States: A Systematic Review. J Palliat Med. 2006;9(6):145473.

23. Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments. JAMA. 2008;299(1):70-78. 24. Eversley R, Estrin D, Dibble S, Wardlaw L, Pedrosa M, Favila-Penney W. Post-Treatment Symptoms among Ethnic Minority Breast Cancer Survivors. Oncol Nurs Forum. 2005;32(2):250-56. 25. Im EO, Chee W, Guevara E. Gender and Ethnic Differences in Cancer Pain Experience: A Multiethnic Survey in the United States. Nurs Res. 2007;56(5):296-306. 26. Green C, Todd KH, Lebovits A, Francis M; American Academy of Pain Medicine Council on Ethics. Disparities in Pain: Ethical Issues. Pain Med. 2006;7(6):530-33. 27. Foley K. Controlling Cancer Pain. Hosp Prac. 2000;35(4): 111-12. 28. Lillie-Blanton M, Rushing OE, Ruiz S. Key Facts: Race, Ethnicity & Medical Care. Kaiser Family Foundation. Update June 2003. Available at: http://www.kff.org/minorityhealth/upload/Key-FactsRace-Ethnicity-Medical-Care-Chartbook.pdf. Accessed January 2011. 29. Bernabei R, Gambassi G, Lapane K, et al. Management of Pain in Elderly Patients with Cancer. JAMA. 1998;279(23):1877-82.

Information provided by the Intercultural Cancer Council 713.798.4614 • 713.798.3990 (FAX) Email: icc@bcm.edu • Website: http://iccnetwork.org Cancer Fact Sheets may be downloaded in printable Adobe Portable Document Format (pdf) from: http://iccnetwork.org/cancerfacts

Cancer Facts Fatigue and Cancer

WHO WE ARE

e are among the majority of people who experience fatigue throughout our battle with cancer.(1) It is a near universal problem that affects approximately three-fourths or more of us and is the most common side effect of our cancer experience. More than half of us experience fatigue on most days, and it affects our daily lives more than pain or nausea. Fatigue associated with cancer is not the kind that will resolve after we take a nap or get a good night’s sleep, but tends to be more severe and ongoing. For those of us who are fortunate, our fatigue is mild and temporary. For others, it can last for months or sometimes years after treatment and makes going about our daily activities nearly impossible. The impact of our fatigue is profound and affects our ability to work, walk short distances,

be intimate, and meet the needs of our families. We often have difficulty performing even the most simple of tasks such as cooking, cleaning, or showering. Some of us experience difficulty concentrating or making relatively simple decisions. Fatigue even causes us to feel distant from our friends and social networks. We refer to our specific type of fatigue as CRF (cancer-related fatigue). It is one of the most debilitating yet least understood or addressed side effects of cancer treatment.(1) Although the majority of us as patients experience fatigue, it is also one of the most overlooked and under-treated side effects of cancer. In fact, CRF is now the most important untreated side effect of cancer today.(1,2) It is by far the most problematic symptom that affects our overall quality of life.

Causes/Etiology ●

Cancer-related fatigue (CRF) is a multi-factorial, multidimensional phenomenon that consists of physical, psychological, social, cognitive, and behavioral aspects.(3)

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Possible causes of fatigue after completion of cancer treatment are still not confirmed.(3)

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The exact cause of cancer-related fatigue is unknown; however, anemia and lack of sleep have both been strongly associated with its onset.(4-6)

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Depression has been positively associated with CRF. Psychostimulants used in the treatment of depression have been shown to decrease fatigue levels.(5)

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Stress has been shown to increase fatigue in healthy individuals and could be a contributor to the fatigue levels in cancer patients.(5)

We feel completely exhausted – physically, emotionally and mentally. The exact cause of our CRF is unknown. Sometimes the root of our fatigue is caused by the cancer itself; in other instances, it is caused by the treatment. What we do know is that cancer-related fatigue can be caused by a variety of other factors such as dehydration, depression, anemia, electrolyte imbalances, decreased nutrition, and medications.(1) There is often more than one contributing cause. It is not predictable by tumor type, treatment or stage of illness. Usually, our CRF comes on suddenly, does not result from activity or exertion, and is not relieved by rest or sleep. We often describe it as “paralyzing” and may continue even after our treatment is complete.

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The most well-identified causes of CRF in adults and children include the natural progression of the disease, poor nutrition, depression, and anemia. Specifically, some studies have found that in addition to other physiological factors, CRF might be induced by the loss of nutrients as a result of anorexia, nausea, vomiting, or hyper-metabolism.(6)

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At present, the etiology of CRF is poorly understood and the relative contributions of the neoplastic disease, various forms of cancer therapy, and comorbid conditions remain unclear.(7)

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Patients with lung cancer have self-reported higher levels of fatigue than patients with cancers of other organs.(8)

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Mild cases of cancer-related anemia have been shown to increase patients’ levels of fatigue; however, high levels of CRF have also been reported by cancer patients without anemia.(8,9)

Project Director Nicholas K. Iammarino, PhD, CHES These ICC Cancer Fact Sheets were updated through an educational grant from Ortho Biotech.

Research Assistants Mohammed Ansar Ahmed Prem Ramkumar

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Fatigue is the most prevalent symptom of individuals with cancer who receive radiation therapy, cytotoxic chemotherapy, or biological response modifiers. (6, 10)

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Physiological factors that contribute to the development of CRF are interrelated. These proposed mechanisms include abnormal metabolism function related to increased energy requirements (e.g. due to tumor growth, infection, fever, or surgery); decreased availability of metabolic substrate (e.g. due to anemia, hypoxemia, or poor nutrition); or the production of substances that impair metabolism or normal functioning of muscles (e.g. cytokines or antibodies). (6, 10)

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Okuyama et al. reported no relationship between fatigue and stage of disease. However, others have reported that patients whose cancer has metastasized have described higher levels of cancer-related fatigue. (11)

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Cancer-related fatigue is believed to be caused by cancer and compounded by the effects of cancer therapy. Studies have shown that fatigue is usually noticed before treatment begins. (12)

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The occurrence of cancer related fatigue has been linked to physiological and psychological disorders including anemia, stress, insomnia, and depression. (13)

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Multiple studies have found the greatest amount of fatigue to be during periods of less daytime activity (more daytime sleep) and less nighttime rest (more night time activity). (15, 16)

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Barriers to effective management of cancer-related fatigue include a lack of awareness that fatigue is the most prevalent symptom, a lack of physician and patient knowledge of its causes, and a lack of proven treatment methods. (17)

Screening ●

Authors report there is a lack of adequate assessment instruments for measuring the different subjective dimensions of fatigue whose properties have been sufficiently psychometrically tested. (11, 17)

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Most clinical assessments of CRF rely on self-reports by patients, although this assessment method is both an asset and a liability. While these symptoms are best measured by patients themselves, the sickest patients may not be able to complete these assessments. (17)

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Assessment should include discussion about common symptoms experienced by cancer patients. Repeated assessments for these symptoms should continue over the course of the illness. (17)

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Although multidimensional assessment instruments for CRF exist, they are often not feasible for use in cancer care. Brief symptom rating scales are preferred in clinical practice settings. (17)

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Cancer-related fatigue is left unaddressed by physicians because it is a condition that can persist long after treatments have ended. (18)

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Fatigue scales used to measure the severity of fatigue do not account for the patients’ perception of fatigue. Therefore, a quantitative measure of fatigue is usually not possible. (19)

Symptoms of cancer-related fatigue have shown a high correlation to the blood levels of circulating cytokines. (14)

DEFINING CANCER-RELATED FATIGUE The National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology (1) defines cancerrelated fatigue (CRF) as: “a persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning.” The NCCN Consensus Panel further states that: “Compared with the fatigue experienced by healthy individuals, cancerrelated fatigue is more severe, more distressing, and less likely to be relieved by rest. In terms of the defining characteristics, it is important to note the subjective sense of tiredness reported by the patient. As with pain, the clinician must rely on patients’ descriptions of their fatigue and accompanying distress. Fatigue that interferes with usual functioning is another substantial component of the definition for cancer-related fatigue and the source of much distress for patients.” (1)

Fatigue and Cancer

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Generally, fatigue scales rely on patients’ self-report, which can be problematic as clinical interpretation of the scores can vary from patient to patient and among the various scales.(19 - 21)

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Cancer-related fatigue has occupational repercussions, sometimes causing patients to discontinue or change employment, go on disability, or use unpaid family and medical leave because of their extreme fatigue.(2)

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Research has shown that non-pharmacological interventions can be beneficial by providing patients with preparatory knowledge about their disease and treatment. Nonpharmacologic treatments for CRF include: patient education, exercise, modification of activity and rest patterns, stress management and cognitive therapies, and adequate nutrition and hydration.(6)

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In some women with breast cancer who are receiving chemotherapy, a home-based exercise program of low to moderate intensity has shown to be a feasible and effective way to reduce the effects of fatigue as well as improve quality of life and functional ability.(6, 15, 26, 28)

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Patients receiving radiotherapy begin with a lower level of fatigue that rises gradually as treatment progresses and decreases once treatment ends.(15)

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The large range found for CRF prevalence (4-91%) suggests a lack of uniformity in measurement methodology. Lack of consistency in estimates of symptoms across studies could be attributed to an inability to agree on the criteria to define these symptoms. There is also a lack of consensus on the most valid and reliable measures.(17)

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At present, published studies on CRF have focused on prevalence data because there are no reliable studies on its incidence.(17)

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Studies have shown that patients adapt to their condition during treatment to distance themselves from the disease. They begin to consider their condition normal and may report their fatigue as less severe.(24)

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Often, patients do not report episodes of cancer-related fatigue to their physicians and/or other health professionals due to its lack of perceived severity. These patients tend to adjust to more sedentary activities, change their daily schedules, and decrease their productivity.(2, 3, 15, 25)

Disparities ●

CRF symptoms, alone or in combination, may be perceived and managed differently in children and adolescents, older adults, those from low-income or low-educational backgrounds, and those from ethnically and culturally diverse groups.(17)

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Evidence regarding the treatment of fatigue in children and adolescents, older persons, and other special populations is insufficient.(17)

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Although the relationships between fatigue and demographic characteristics, physiologic factors, and psychosocial factors are not well-defined, findings from Eversley et al. show that increased levels of post-treatment symptoms, including fatigue, exist among minorities and are also associated with decreased income.(22)

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Eversley et al. found that Latinas reported significantly higher rates of fatigue than African American/black and nonHispanic/Latino women with breast cancer.(22)

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Fatigue is a commonly reported symptom among children and adolescents with cancer. However, the mechanisms, risk factors, clinical features, prevalence and duration are poorly understood. At present, no therapeutic interventions are available.(23)

Outcomes ●

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Fatigue is one of the most prevalent side effects during chemotherapy, usually persisting for more than two weeks; also, it has been shown to have the greatest and most longlasting impact after chemotherapy.(2) Patients who experience daily cancer-related fatigue are also more likely to be experiencing pain and other psychosocial symptoms such as depression, lack of motivation, and disturbances in mood and cognition.(2)

Fatigue and Cancer

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Some patients do not discuss their fatigue with a health care professional because they assume CRF is a normal and expected outcome of their cancer treatment, that it would not continue to persist, that it was caused by the cancer itself, or that nothing could be done to alleviate their fatigue.(3, 25)

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Studies report that the number of people affected by cancerrelated fatigue falls between the range of 60-100%; many report an average of 75%.(6, 25)

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Cancer-related anemia, a symptom highly associated with cancer-related fatigue, can be effectively treated without the use of blood transfusions. Epoetin alfa, the most clinically used drug intervention for cancer-related anemia, has been shown to increase hemoglobin levels in anemic cancer patients receiving chemotherapy.(9, 15, 17, 26, 27)

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Many patients report experiencing physical manifestations of fatigue at least a few days each month, such as a significantly diminished energy level, a need to slow down from a normal pace, a general sense of sluggishness or tiredness, and an increased need for sleep or rest.(2, 28, 29) Exercise reduces fatigue by improving physical efficiency and performance through gains in muscle mass and plasma volume, improved pulmonary ventilation and perfusion, increased cardiac reserve, and higher concentrations of oxidative muscle enzymes.(29)

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Ancoli-Israel et al. have found that women with breast cancer report disruptions in sleep and higher levels of fatigue prior to receiving treatment.(30)

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Fatigue causes substantial functional and psychological impairment, and is rarely discussed or treated. Many patients report that fatigue affects the quality of their daily lives by preventing them from leading a normal life and forcing them to alter their daily routine.(2, 31)

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Berger and Higginbotham found that patients most often experienced pain along with their fatigue. The next highest association was found to be between sleeping problems and depression.(11, 31)

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Breast cancer patients experience a “roller coaster” pattern of fatigue, in which the experience of fatigue is significantly greater at the start of each treatment cycle than it is at the midpoint.(32)

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In patients receiving multiple forms of treatment for cancer, a “response shift” during the initial treatment may influence perceptions of fatigue during the second treatment, as patients become accustomed to their fatigue. Response shift is defined as a re-conceptualization of the quality of life brought about by a change in health status.(10, 32)

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Studies suggest that fatigue gradually decreases after the last treatment. However, fatigue is still a frequent complaint by disease-free cancer patients months and years after curative treatment for cancer has ended.(3, 6, 11, 32)

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Lung cancer patients report that fatigue was the most frequent symptom that interfered with their daily lives. (33)

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During the first 24 to 48 hours of chemotherapy, a sharp rise in fatigue levels has been observed.(34) After the first two weeks of therapy, fatigue levels continue to rise slightly and begin to decrease once treatment ends. (10,15, 32)

Fatigue and Cancer

WEB RESOURCES

The American Cancer Society is the nationwide community-based voluntary health organization dedicated toeliminating cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and service.

National Cancer Institute www.cancer.gov The National Cancer Institute (NCI) is a component of the National Institutes of Health (NIH), one of eight agencies that compose the Public Health Service (PHS) in the Department of Health and Human Services (DHHS). The NCI, established under the National Cancer Act of 1937, is the Federal Government’s principal agency for cancer research and training.

American Pain Foundation www.painfoundation.org As a nonprofit information resource for people with pain that provides practical information for patients, the American Pain Foundation raises public awareness and understanding of pain and promotes better pain management.

National Comprehensive Cancer Network www.nccn.org The National Comprehensive Cancer Network (NCCN), an alliance of 19 of the world’s leading cancer centers, is an authoritative source of information to help patients and health professionals make informed decisions about cancer care.

American Society of Clinical Oncology www.asco.org The American Society of Clinical Oncology (ASCO) is the world’s leading professional organization representing physicians who treat people with cancer. ASCO’s efforts are directed toward advocating for policies that provide access to high-quality care for all patients with cancer and at supporting the increased funding for clinical and translational research.

National Ovarian Cancer Coalition (NOCC) www.ovarian.org The NOCC provides patients and the medical community with information about ovarian cancer, (i.e. facts, treatments, peer-support forum, database of cancer-related resources).

American Cancer Society

www.cancer.org

CancerCare www.cancercare.org CancerCare is a national non-profit organization that provides free professional support services to anyone affected by cancer: people with cancer, caregivers, children, loved ones, and the bereaved. Chemo Care www.chemocare.com A program of the Scott Hamilton CARES Initiative (the Cancer Alliance for Research Education and Survivorship), this is Scott Hamilton’s personal program designed to promote cancer awareness while raising significant funds for cancer research. Department of Pain Medicine & Palliative Care at Beth Israel Medical Center www.stoppain.org This is a resource that provides patients and the medical community with information about pain management and palliative care. Also addresses the physical, psychosocial, and spiritual concerns of patients with lifethreatening illnesses (i.e. facts, treatments, educational programs, resources, clinical trials).

Fatigue and Cancer

OncoLink www.oncolink.upenn.edu Founded by University of Pennsylvania cancer specialists, Oncolink provides cancer patients, families, healthcare professionals and the general public with comprehensive information about cancer, its treatments and research initiatives. Oncology Nursing Society www.ons.org The ONS provides oncology nurses, healthcare professionals and patients with access to educational programs, cancer-care resources and peer-support networks. People Living With Cancer www.plwc.org People Living With Cancer, the patient information website of the American Society of Clinical Oncology (ASCO), is designed to help patients and families make informed health-care decisions. The site provides information on more than 85 types of cancer. The purpose of this and other ICC Fact Sheets is to draw attention to the cancer disparities that exist among various medically underserved populations. With specific regard to cancer-related fatigue (CRF), at present there is a dearth of scientific research on this subject reported in the medical literature.

References 1.

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13.

14.

The National Comprehensive Cancer Network and the American Cancer Society. Cancer-Related Fatigue and Anemia Treatment Guidelines for Patients (version II). Atlanta, 2003. Curt G, Breitbart W, Cella D, et al. Impact of CancerRelated Fatigue on the Lives of Patients: New Findings from the Fatigue Coalition. The Oncologist. 2000;5: 353-60. Servaes P, Verhagen S, Bleijenberg G. Determinants of Chronic Fatigue in Disease-free Breast Cancer Patients: A Cross-Sectional Study. Ann Oncol. 2002;13:589-98. Cell D, Lai JS, Chang CH, Peterman A, Slavin M. Fatigue in Cancer Patients Compared with Fatigue in the General United States Population. Cancer. 2002;94(2):528-38. Brix C, Schleußner C, Füller J, Röhrig B, Strauß B. Fatigue and its Determinants in Radio Oncology. Psychother Psychosom Med Psychol. 2008;DOI: 10.1055/s-2008-1067341. Ahlberg K, Ekman T, Gaston-Johansson F, Mock V. Assessment and Management of Cancer Related Fatigue in Adults. Lancet. 2003;362: 640-50. Ryan JL, Carroll JK, Ryan EP, Mustian KM, Fiscella K, Morrow GR. Mechanisms of Cancer-Related Fatigue. The Oncologist. 2007; 12(1):22-34. Holzner B, Kemmler G, Greil R, et al. The Impact of Hemoglobin Levels on Fatigue and Quality of Life in Cancer Patients. Ann Oncol. 2002;13(6): 965-73. Cortesi E, Gasco P, Henry D, et al. Standard of Care for Cancer-Related Anemia: Improving Hemoglobin Levels and Quality of Life. Oncology. 2005;68: 22–32. De Jong N, Courtens A, Abu-Saad H, Schouten H. Fatigue in Patients With Breast Cancer Receiving Adjuvant Chemotherapy: A Review of the Literature. Cancer Nurs. 2002;25(4): 283-97. Okuyama T, Akechi T, Kugaya A, Okamura H, Imoto S, Nakano T. et al. Factors Correlated With Fatigue in Disease-free Breast Cancer Patients: Application of the Cancer Fatigue Scale. Support Care Cancer. 2000;8(3):215-22. Langeveld NE, Grootenhuis MA, Voute PA, De Haan RJ, van den Bos C. No Excess Fatigue in Young Adult Survivors of Childhood Cancer. Eur J Cancer. 2003;39(2):204-14. Van Belle S, Paridaens R, Evers G, Kerger J, Bron D, Foubert J. Comparison of Proposed Diagnostic Criteria With FACT-F and VAS for Cancer-Related Fatigue: Proposal for Use as a Screening Tool. Support Care Cancer. 2005;13(4):246-54. Meyers C, Albitar M, Estey E. Cognitive Impairment, Fatigue, and Cytokine Levels in Patients With Acute Myelogenous Leukemia or Myelodysplastic Syndrome. Cancer. 2005;104(4):788-93.

15. Wells J, Fedric T. Helping Patients Manage CancerRelated Fatigue. Home Healthc Nurse. 2001;19(8):48694. 16. Ancoli-Israel S, Moore PJ, Jones V. The Relationship Between Fatigue and Sleep in Cancer Patients: A Review. Eur J Cancer Care. 2001;10:245-55. 17. Patrick DL, Ferketich SL, Frame PS, et al. National Institutes of Health State-of-the-Science Panel. National Institutes of Health State-of-the-Science Conference Statement: Symptom Management in Cancer: Pain, Depression, and Fatigue, July 15-17, 2002. J Natl Cancer Inst. 2003;95(15): 1110-17. 18. Perry S, Kowalski TL, Chang CH. Quality of Life Assessment in Women with Breast Cancer: Benefits, Acceptability and Utilization. Health Qual Life Outcomes. 2007;5:24. 19. Gielissen MF, Knoop H, Servaes P, et al. Differences In the Experience of Fatigue in Patients and Healthy Controls: Patients’ Descriptions. Health Qual Life Outcomes. 2007;5:12. 20. Hjollund, NH, Andersen JH, Bech P. Assessment Of Fatigue in Chronic Disease: A Bibliographic Study of Fatigue Measurement Scales. Health Qual Life Outcomes. 2007;5:12. 21. Lawrence DP, Kepelnich JH, Miller K, Devine D, Lau J. Evidence Report on the Occurrence, Assessment, and Treatment of Fatigue in Cancer Patients. J Natl Cancer Inst Monogr. 2004;(32):40-50. 22. Eversley R, Estrin D, Dibble S, Wardlaw L, Pedrosa M, Favila-Penney, W. Post-Treatment Symptoms Among Ethnic Minority Breast Cancer Survivors. Oncol Nurs Forum. 2005;32(2): 250-56. 23. Gibson F, Garnett M, Richardson A, Edwards J, Sepion B. Heavy to Carry: A Survey of Parents’ and Healthcare Professionals’ Perceptions of CancerRelated Fatigue in Children and Young People. Cancer Nurs. 2005; 28(1):27-35. 24. Westerman MJ, The AM, Sprangers MAG, Groen HJM, Wal G, Hak T. Small-Cell Lung Cancer Patients are Just ‘A Little Bit’ Tired: Response Shift and SelfPresentation in The Measurement of Fatigue. Qual Life Res. 2007;16(5):853-61. 25. Morrow GR, Andrews PL, Hickok JT, Roscoe JA, Matteson S. Fatigue Associated with Cancer and its Treatment. Support Care Cancer. 2002;10:389-98. 26. Stasi R, Abriani L, Beccaglia P, Terzoli E, Amadori S. Cancer-Related Fatigue: Evolving Concepts in Evaluation and Treatment. Cancer. 2003;98(9):17861801. 27. Gabrilove JL, Cleeland CS, Livingston RB, Sarokhan B, Winer E, Einhorn LH. Clinical Evaluation of OnceWeekly Dosing of Epoetin Alfa in Chemotherapy Patients: Improvements in Hemoglobin and Quality of Life are Similar to Three-Times Weekly Dosing. J Clin Oncol. 2001;19:2875-82.

Fatigue and Cancer

28. Turner J, Hayes S, Reul-Hirche H. Improving the Physical Status and Quality of Life of Women Treated for Breast Cancer: A Pilot Study of a Structured Exercise Intervention. J Surg Oncol. 2004;86:141-46. 29. Winningham M. Strategies for Managing CancerRelated Fatigue Syndrome: A Rehabilitation Approach. Cancer. 2001;92(4):988-97. 30. Ancoli-Israel S, Liu L, Marler MR, et al. Fatigue, Sleep and Circadian Rhythms Prior to Chemotherapy for Breast Cancer. Support Care Cancer. 2006; 14(3):2019. 31. Mock V, Pickett M, Ropka M, et al. Fatigue and Quality of Life Outcomes of Exercise During Cancer Treatment. Cancer Pract. 2001;9:119-27.

Fatigue and Cancer

32. Donovan K, Jacobsen P, Andrykowski M, et al. Course of Fatigue in Women Receiving Chemotherapy and/or Radiotherapy for Early Stage Breast Cancer. J Pain Symptom Manage. 2004;28(4):373-80. 33. Tanaka K, Akechi T, Okuyama T, Nishiwaki Y, Uchitomi Y. Impact of Dyspnea, Pain, and Fatigue on Daily Life Activities in Ambulatory Patients with Advanced Lung Cancer. J Pain Symptom Manage. 2002;23(5):417-23. 34. Schwartz AL. Daily Fatigue Patterns and Effect of Exercise in Women with Breast Cancer. Cancer Pract. 2000;8(1):16-24.

Cancer Facts Workplace and Cancer

WHO WE ARE

e are among the 34,000 individuals who will die from cancer due to exposure from cancercausing substances in the workplace in the United States.(1) Millions more of us are exposed to substances that have been shown to be carcinogenic in animal studies. However, fewer than 2% of chemicals found in the workplace have been tested for their carcinogenicity.(2) Thus, many more of us develop cancer from preventable workplace exposures. Of those who develop or die from workplace-related cancer, a disproportionate number of us are poor, have little formal

education, and are part of a minority or underserved group. We are workers who have few employment options and thus we often work in industries, such as construction, printing, and agriculture, where exposure to carcinogens is more likely unless rigorous efforts are made to protect us as workers. Unfortunately, since many of us are low-income minority and migrant workers, we are sometimes limited to employment in substandard work environments. Often we do not receive or do not understand information on how to protect our health and that of

Causes/Etiology ●

Of the 27 million US workers exposed to asbestos before the 1970s, 8,000 will die from asbestos-related cancer each year. These workers are exposed in the mining and milling of asbestos, during the manufacture of all asbestos products, and in the construction and ship building industries. Worker exposure also occurs in asbestos end-product use occupations, such as asbestos insulation workers, brake repair and maintenance workers, building demolition workers, and asbestos abatement workers.(3)

●

In a two-year period, The National Occupational Exposure Survey (NOES) estimated that 153,937 total workers, including 7,603 women were potentially exposed to asbestos.(4)

●

The National Institute for Occupational Safety and Health (NIOSH) estimates 20,000 cancer deaths and 40,000 new cancer diagnoses annually in the United States secondary to occupational exposure to carcinogens.(2)

our families who may be secondarily exposed to carcinogens that we bring home on our clothes. Additionally, as workers we often live in areas that further expose us, and our families to carcinogens and other environmental health hazards. Toxic waste sites, freeways, nuclear facilities, and chemical plants are more frequently located in our poor, minority neighborhoods than in more affluent areas. We often cannot afford regular health care and therefore, our cancers are often diagnosed at a late stage at which time there are few effective treatment options.

●

The development of malignant mesothelioma is directly linked to asbestos. Most people who develop this type of cancer are exposed to asbestos in their workplace. Occupations with the highest risk include shipbuilding, mining, insulation manufacturing and installation and Navy workers.(5)

●

The World Health Organization established the Comparative Risk Assessment project in 2000. The goal of this project was to assess the morbidity and mortality secondary to occupational hazards. The results of the study showed occupational hazards were responsible for 9% of newly diagnosed lung cancer, 2% of new cases of leukemia and 100% of new cases of mesothelioma in 2000.(6)

●

The following occupations are associated with nonmelanoma skin cancer: railway engines, firemen, miners, quarrymen. The development of cancer is associated with exposure to hazardous air pollutants, arsenic, ionizing radiations and burns.(7)

Project Director Nicholas K. Iammarino, PhD, CHES These ICC Cancer Fact Sheets were updated through an educational grant from Ortho Biotech.

esearch Assistants Mohammed Ansar Ahmed Prem Ramkumar

●

Radioactive emissions account for approximately 1/9 of childhood cancers. The children are often 10 years or younger and live within a 31 mile radius of a nuclear plant. After the plants are closed, there is a reduction in the number of new childhood cancer diagnoses.(8)

●

Leukemia has been associated with exposure to benzene, either alone or in combination with other chemicals. An estimated 3 million workers may be exposed to benzene due to their work as car mechanics and road tanker drivers.(9)

●

Four percent of all cancer deaths in the U.S. are thought to be related to exposures in the workplace.(3)

●

NIOSH estimates that 10% of lung cancer, 21% to 27% of bladder cancers, and nearly 100% of mesotheliomas in the U.S. population are caused by occupational exposures to carcinogens.(3)

●

Nearly 100% of workers with documented exposure to vinyl chloride will develop angiosarcoma of the liver, and nearly 50% with exposure to asbestos will develop lung cancer.(3)

●

Several epidemiological studies have shown an excess of lung cancer among workers exposed to coal tar fumes in coal gasification and coke production. Similarly, epidemiological studies have also shown excesses of lung and urinary bladder cancer among workers exposed to pitch fumes in aluminum production plants.(4)

●

Studies have reported strong associations of cancers of the nasal cavities and paranasal sinuses in people whose occupations are associated with wood dust exposure.(4)

●

A 2003 study demonstrated an increased risk among male hairdressers for cancers of the upper aerodigestive tract, lung, and colon; among female hairdressers an increased risk for cancers of the pancreas, lung, cervix, and skin (especially the scalp and neck) was noted.(10)

●

Exposure to vinyl chloride, primarily from polyvinylchloride (PVC) production plants, has been associated with a five-fold increase in liver cancer among workers, primarily due to a 45- fold increase in angiosarcomas, a liver tumor that normally only accounts for 2% of liver tumors in the U.S.(11)

●

Numerous studies have demonstrated that diesel truck drivers are approximately 50% more likely to have lung cancer than are other workers.(16,17)

●

Male machinery repairers, metal processing workers, industrial spray painters, and tanners/fur dressers have an increased risk of breast cancer.(18)

●

A recent study showed a significantly elevated risk of leukemia and non-Hodgkin lymphoma in children of parents that are exposed to ionizing radiation prior to their conception.(8)

●

Approximately 20% of bladder cancers can be attributed to environmental exposures. A chemical that is proven to cause bladder cancer is benzedine, which is used in dye and rubber industries.(19)

●

The Agricultural Health Study demonstrated that the development in colorectal cancer is possibly linked to chemicals used for agricultural pesticides.(20)

Disparities ●

Hispanics/Latinos are more likely than non-Hispanic/Latino whites to work in service occupations (20% vs. 13%) and also are more likely to be employed in construction and maintenance (27% vs. 18%).(21)

McElroy et al. reported a slightly increased risk for the development of breast cancer in women exposed to electromagnetic fields in their workplace.(13)

●

In 2001-02, 78% of all farm workers were foreign-born, and 75% of these were born in Mexico. Three out of five farm worker families had incomes below the poverty level.(22)

●

A recent cohort study confirmed an increased risk of cancer in carpenters and cabinet makers secondary to exposure to chemicals used in their jobs, such as varnishes, lacquers, epoxy resins and polyvinyl acetate.(14)

●

About 68% of urban African American/black children from low income families were reported to have lead levels exceeding safe limits, compared to only 15% of their nonHispanic/Latino white counterparts, who are largely from affluent families.(23)

●

Studies indicate that painters have an increased risk for lung cancer and cancers of the esophagus, stomach and bladder, possibly due to various carcinogens used in paint products such as pigments, extenders, binders, solvents, and additives.(15)

●

Approximately 50% of Hispanics/Latinos younger than 65 years of age and 66% of working aged Hispanics/Latinos with low incomes are uninsured. Most of the working uninsured are not offered health benefits and are employed in jobs with the highest risk for any occupational injury.(24)

●

Researchers have found an increased risk of lung and liver cancer among iron foundry workers, especially those who were short-term or temporary workers.(12)

●

Workplace and Cancer

Outcomes

●

Hispanics/Latinos, 15.8% of the U.S. population, account for 44% of the private household cleaners and servants, 29% of janitors and building cleaners, 42% of maids and housekeeping cleaners, 33% of construction laborers, 31% of laundering and dry-cleaning machine operators, 57% of drywall installers, 42% of tile setters, and 52% of concrete and terrazzo finishers.(25) African Americans/blacks, who comprise 12.9% of the U.S. population, account for 17% of janitors and building cleaners, 16% of maids and housekeeping cleaners, 21% of textile pressing machine operators, 18% of laundering and drycleaning machine operators, 25% of bus drivers, 35% of barbers, and 28% postal clerks.(25)

●

African American/black men are more than twice as likely as non-Hispanic/Latino white men to work in service occupations (19% vs. 8%), and nearly twice as likely (28% vs. 16%) to be operators, fabricators, and laborers.(26)

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African American/black women are more likely to be employed in service occupations (27% vs. 15%) or as operators, fabricators, and laborers (9% vs. 5%) than nonHispanic/ Latino white women.(26)

●

Elevated mortality rates from cervical cancer in female farm workers may be related to poor access to medical care.(33)

●

A study of workers in the state of Iowa related a significantly higher incidence of pancreatic cancer in men employed by companies producing chemical and allied products and in women who worked as textile sewing machine operators.(34)

●

There is well-documented evidence supporting the development of bladder cancer in long term workers of the rubber industry due to long term exposure to carcinogenic aromatic compounds. Such long term exposure may also be associated with the development of leukemia, stomach or lung cancer.(35)

●

In a study that examined data from 21 states during 19851992, Hispanic/Latino men who worked as cleaners and materials handlers experienced a four-fold increase in mortality from leukemia when compared with all U.S. workers. This same study found that African American/black women who worked in construction or as motor vehicle operators were two times more likely to die from lung cancer than other African American/blacks.(36)

●

Among African American/black men, a two-fold increase in deaths from leukemia has been associated with employment in the rubber and plastic manufacturing industry.(36)

●

Among Hispanic/Latino men, excess deaths from leukemia have been associated with employment in the textile and clothing industry, and in lumber and wood product manufacturing.(36)

●

Workers at high risk of airborne exposure to aflatoxin are those involved in agriculture as they are occupationally exposed through the inhalation of grain dust. A 10% increase in hepatocellular cancer incidence was observed in an area in the southeast United States compared with areas with low aflatoxin intake.(18)

●

Cancer accounts for 34% of estimated global work-related mortality, higher than any other single factor, including physical injury.(37)

●

African American/black men are twice as likely to have increased cancer incidence from occupational exposures than non-Hispanic/Latino white men.(3)

●

Compared with the general Hispanic/Latino population, California Hispanic/Latino farm workers are 59% more likely to develop certain types of leukemia, 70% more likely to develop stomach cancer, 63% more likely to develop cervical cancer, and 68% more likely to develop uterine cancer.(27)

Compared with the general U.S. population, dry cleaning workers are at increased risk for cancers of the esophagus, larynx, lung, and cervix as well as for cancer mortality in general. Korean Americans operate approximately 50% of Oregon’s dry cleaners.(28-30)

●

Women employed in the paper and pulp industry have shown increased rates of ovarian, lung and bladder cancer.(31)

●

Blue-collar women exposed to solvents in the chemical and pharmaceutical industries experience increased risk of breast cancer. (32)

Workplace and Cancer

References

4. 5.

American Cancer Society. Cancer Facts and Figures 2010. Atlanta, Ga: 2006. NIOSH Safety and Health Topic: Occupational Cancer. Available at: http://www.cdc.gov/niosh/ topics/cancer/. Accessed August 2010. National Institute for Occupational Safety and Health. NIOSH Workplace Safety and Health Topics. Available at: http://www.cdc.gov/niosh/topics/asbestos/ Accessed August 2010. US Department of Health and Human Services. Carcinogens. 10th Edition; Washington DC 2002. Creaney J, Robinson BW. Detection of Malignant Mesothelioma in Asbestos Exposed Individuals: The Potential Role of Soluble Mesothelin Related Protein. Hematol Oncol Clin North Am. 2005;19(6):1025-40, v.

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Fingerhut M, Nelson DI, Driscoll T, et al. The Contribution of Occupational Risks to the Global Burden of Disease. Med. Lav. 2006; 97(2):313-21. Suárez B, López-Abente G, Martínez C, Navarro C, Tormo MJ, Rosso S et al. Occupation and Skin Cancer: The Results of the HELIOS-I Multicenter Case-Control Study. BMC Public Health. 2007;7(147):180. Buka I, Koranteng S, Osornio Vargas AR, et al. Trends in Childhood Cancer Incidence: Review of Environmental Linkages. Pediatr Clin North Am. 2007;54(1):177-203,x. International Agency for Research on Cancer (IARC). IARC Monographs on the Evaluation of the Carcinogenic Risk of Chemicals to Humans. Some Industrial Processes and Industries Associated with Cancer in Humans. Lyon, France. 2006. Czene K, Tiikkaja S, Hemminki K. Cancer Risks in Hairdressers: Assessment of Carcinogenicity of Hair Dyes and Gels. Int J Cancer. 2003;105(1):108-12. Kielhorn J, Melber C, Wahnschaffe U, Aitio A, Mangelsdorf I. Vinyl Chloride: Still a Cause for Concern. Environ Health Perspect. 2000;108(7):579-88. Adzersen KH, Becker N, Steindorf K, Frentzel-Beyme R. Cancer Mortality in a Cohort of Male German Iron Foundry Workers. Am J Ind Med. 2003;43(3):295-305. McElroy J, Egan KM, Titus-Ernstoff L, et al. Occupational Exposure to Electromagnetic Field and Breast Cancer Risk in a Large, Population Based, Case Control Study in the United States. J Occup Environ Med. 2007;49(3):266-74. Stang A, Ahrens W, Baumgardt-Elms C, Bromen K, Stegmaier C, Jöckel KH. Carpenters, Cabinetmakers, and Risk of Testicular Germ Cell Cancer. J Occup Environ Med. 2005;47(3):299-305. International Agency for Research on Cancer (IARC). IARC Monographs Programme finds cancer hazards associated with shiftwork, painting and firefighting. Lyon, France, 2007. Jarvholm B, Silverman D. Lung Cancer in Heavy Equipment Operators and Truck Drivers with Diesel Exhaust Exposure in the Construction Industry. Occup Environ Med. 2003;60(7): 516-20. Davis ME, Smith TJ, Laden F, et al. Driver Exposure to Combustion Particles in the US Trucking Industry. J Occup Environ Hyg. 2007: 4(11):848-54. Pollan M, Gustavsson P, Floderus B. Breast Cancer, Occupation, and Exposure to Electromagnetic Fields among Swedish Men. Am J Indus Med. 2001;39(3):276-85. Kirkali Z, Chan T, Manoharan M, Algaba F, Busch C, Cheng L. Bladder Cancer: Epidemiology, Staging, Grading and Diagnosis. Urology. 2005;66(6 Suppl 1):4-34. Lee WJ, Sandler DP, Blair A, Samanic C, Cross AJ, Alavanja MC. Pesticide Use and Colorectal Cancer Risk in the Agricultural Health Study. Int J Cancer. 2007;121(2):339-46. U.S. Census Bureau. Hispanics in the United States. Available at: http://www.census.gov/population/ www/socdemo/hispanic/files/Internet_Hispanic_in_US_20 06.pdf. Accessed August 2010.

22. Mehta K, Gabbard SM, Barrat V, Lewis M, Carroll D, Mines R. Findings from the National Agricultural Workers Survey (NAWS): A Demographic and Employment Profile of United States Farmworkers. U.S. Department of Labor, Office of the Assistant Secretary for Policy, Office of Program Economics, Research Report No. 9. 2005. 23. Olden K, White SL. Health Related Disparities and Environmental Factors. Med Clin North Am. 2005;89(4):721-38. 24. Diaz VA Jr. Hispanic Male Health Disparities. Prim Care. 2006;33(1):45-60, viii. 25. U.S. Department of Labor, Bureau of Labor Statistics. Employed Persons by Detailed Occupation, Sex, Race, and Hispanic Origin. Household Data Annual Averages, 2009. Available at: http://www.bls.gov/cps/cpsaat11.pdf. Accessed August 2010. 26. McKinnon, J. The Black Population in the United States: March 2002. U.S. Census Bureau, Current Population Reports, Series P20-541: Washington, DC, 2003. Available at: http://www.census.gov/prod/2003pubs/p20- 541.pdf. Accessed August 2010. 27. Mills PK, Kwong S. Cancer Incidence in the United Farmworkers of America (UFW), 1987-1997. Am J Ind Med. 2001;40(5):596-603. 28. Oregon Department of Environmental Quality. Dry Cleaner Program Overview 2003. Available at: http://www.deq. state.or.us/pubs/factsheets.htm#DryCleaner. Accessed August 2010. 29. Ruder AM, Ward EM, Brown DP. Mortality in Dry-Cleaning Workers: An Update. Am J Ind Med. 2001; 39(2):121-32. 30. Blair A, Petralia SA, Stewart PA. Extended Mortality Followup of a Cohort of Dry Cleaners. Annals of Epidemiology, 2003;13(1):50-56. 31. Langseth H, Andersen A. Cancer Incidence among Women in the Norwegian Pulp and Paper Industry. Am J Ind Med. 1999;36(1):108-13. 32. World Resources Institute. Available at: http://www. wri.org/health/slide34.htm. Accessed June 2008. 33. Colt JS, Stallones L, Cameron LL, Dosemeci M, Zahm SH. Proportionate Mortality among US Migrant and Seasonal Farmworkers in Twenty-Four States. Am J Ind Med. 2001;40(5):604-611. 34. Zhang Y, Cantor KP, Lynch CF, Zhu Y, Zheng T et al. Occupation and Risk of Pancreatic Cancer: A PopulationBased Case Control Study in Iowa. J Occup Environ Med. 2005;47:392-98. 35. Mortality and Cancer Incidence among Tire Manufacturing Workers Hired in or after 1962. J Occup Environ Med. 2007;49(3);680-90. 36. Loomis D, Schulz M. Mortality from Six Work-Related Cancers among African Americans and Latinos. Am J Ind Med. 2000;38(5):565-75. 37. World Health Organization. Occupational Health: Ethically Correct, Economically Sound: Geneva, Switzerland, 2005. Available at: http://www.who.int/inf-fs/en/fact084.html. Accessed August 2010.

Cancer Facts Elderly and Cancer

WHO WE ARE

e are people in the United States who are 65 years of age and older. Some of us, aged 65-74 years old are referred to as the “youngerold,” those 75-84 are called “old,” and those of us who are 85 years and older are the “older-old.” We represent a significant segment of the population (more than 12%) and our numbers are expected to more than double by the middle of the 21st century to 86.7 million (21%), or one in five Americans.(1) During the last century our numbers increased tenfold from 3.1 million in 1900 (about 1 in 25 Americans) to 35.0 million in 2000 (about 1 in every 8 Americans).(2) Of the 37.3 million elderly in 2006, about

30 million (85%) of us are nonHispanic/whites, 2.8 million (8%) are African American, and 1.7 million (5%) are Hispanic/Latino. Asian Americans account for 801,000 (2%), American Indians/Alaska Natives account for 138,400 (0.4%), and Hawaiian and Pacific Islanders total 21,000 (0.006%).(3) By the year 2050 under current projections, our numbers in minority populations are expected to outpace non-Hispanic/whites. While the number of elderly non-Hispanic whites is anticipated to double to 62 million, the number of elderly African Americans will nearly quadruple to over 9 million. Elderly Hispanic/

Causes/Etiology ●

About 26% of the elderly have only Medicare coverage compared to about 16% of Americans under the age of 65 who have no health insurance coverage whatsoever. (6)

●

Sociocultural and political barriers interfere with health care access for elderly African American/black women in the rural South. Elderly African American/black women in rural North Carolina report feeling “distanced” from the local health care system and often allow this feeling to translate into delay or avoidance of breast cancer screening or other preventive services. (7)

●

Latinos will total about 12 million; 11 times as many as in 1990. The number of American Indians/Alaska Natives will grow to 562,000, while Asian and Pacific Islander elderly will approach 7 million.(4) Despite this 65 year age limit, we are often recognized as elderly at widely divergent ages depending on our cultural backgrounds. For example, we may be considered elderly as young as 40 years of age for many Southeast Asian subgroups and among some American Indian/Alaska Native populations.(5) Yet in spite of these differences, as elderly people we remain active and vital members of society and our communities.

Screening ●

Mammography and Pap tests are underused by women who are older, members of certain racial and ethnic minority groups, have less than a high school education, or live below the poverty level. (9)

●

Between 60% and 80% of American women with newly diagnosed invasive cervical cancer have not had a Pap test in the past five years. Particularly, elderly, African American/black, and low income women are less likely to have regular Pap tests. (10)

●

Despite the proven effectiveness and availability of various colorectal cancer screening tests, many elderly adults aged 50 and older are not regularly screened. (11)

●

Older African American/black and Hispanic/Latino women are less likely to be screened for breast and cervical cancer than their younger counterparts. (12)

In 2002, only 7% of the Hispanic/Latino elderly population reported having Medicare coverage compare to 79% of nonHispanic/Latino whites. (8)

Project Director Nicholas K. Iammarino, PhD, CHES These ICC Cancer Fact Sheets were updated through an educational grant from Ortho Biotech.

Research Assistant Mohammed Ansar Ahmed Prem Ramkumar

●

Among the elderly, African American/black men are more likely to be diagnosed with advanced prostate cancer than non-Hispanic/Latino white men. Furthermore, the prostate cancer mortality rate for African American/black men is twice as high compared to non-Hispanic/Latino whites. (13)

●

Only 17% of American Indian/Alaska Native women ages 60 and older report ever having a mammogram, compared to 38% of all U.S. women in this age group. (13)

●

Cancer screening rates are low for all Americans, with the lowest rates found among racial and ethnic minorities, lowincome Americans, the elderly and the medically underserved. (14)

●

Hispanic/Latina women aged 50 and older have the lowest mammography utilization rates (63.5%) and Hispanic/ Latina women 18 and over have the lowest Pap test utilization rates (80.9%) compared with other racial and ethnic groups.(15)

●

Older Hispanic/Latino women continue to be less likely to be screened for cancer than younger women and are subsequently often diagnosed at later stages of cancer. (13)

●

More than 40% of Mexican American women aged 75 or older report never having had a mammogram and almost half report never having had a Pap test. (16)

●

Sabatino et al. reported that in 2005, Hispanic/Latina women were less likely than non-Hispanic/Latina women to report breast cancer screening (58.1% vs. 69.0%). (17)

●

The probability of having a Pap test decreases in women over the age of 65 (as compared to those who are younger than 65). (18)

●

African Americans/blacks and Native Americans/Alaska natives treated for colorectal cancer receive less intensive therapy and have poorer survival than non-Hispanic/Latino whites. In addition, older colorectal cancer patients are less likely to receive adjuvant chemotherapy after surgical removal of a colon or rectal tumor than younger patients, partially because of increased chemotherapy toxicity in the elderly. (19)

●

Ninety percent of colorectal cancer cases in the United States occur after age 50. Colorectal cancer incidence per 100,000 by race indicate the following: African American/blacks (61.2%), White (50.1%), Asian and Pacific Islander (40.9%), Hispanic (39.2%) and Native American (43.5%). (6, 20)

●

There is a lack of basic data about aging minority populations. This is largely due to small sample sizes of these populations and to language barriers that prevent certain racial and ethnic groups from participating in survey research. (10)

●

The perception of illness by elderly Asian Americans, which focuses primarily on symptoms, makes it difficult for them to conceptualize and thus seek treatment for diseases such as cancer, hypertension, or diabetes mellitus. (21)

●

According to Lewis and colleagues, 61% of new cancer cases occurred among the elderly in 2003, but only 25% of participants in national cancer clinical trials were over 65 years of age. Moreover, in Phase II and III clinical trials, the elderly carried 60% of the disease burden, but represented only 32% of enrolled patients. (22, 23)

●

African Americans/blacks with cancer have shorter survival times than non-Hispanic/Latino whites at all stages of diagnosis. Relative 5-year survival rates are higher among black persons diagnosed at younger ages (52% among African Americans diagnosed before age 45) than in persons diagnosed at older ages (43% among those diagnosed after age 75). (24)

Disparities ●

Cancer survival rates among elderly American Indian/Alaska Natives are the lowest among all United States subpopulations. (2)

●

Elderly people of color, especially African Americans/blacks and Hispanics/Latinos have a greater number of functional disabilities (restricted activity and bed-disability days) than elderly non-Hispanic/whites. (5)

●

Elderly and certain ethnic groups receive substandard care and generally have poorer mortality outcomes compared to younger, white, or more affluent patients. (19)

Elderly and Cancer

●

Disparities in practice patterns between younger and geriatric patients with bladder cancer exist. A recent study provided evidence that aggressive surgical management of bladder cancer in elderly patients over the age of 80 may improve survival. (25) Based on recent analysis of long-term breast cancer survival among women who have already survived five years after diagnosis, African American/black women are less likely than non-Hispanic/white women to survive an additional five years. (26)

●

In 2006, only 38 % of American Indian/Alaska Native elderly men had a PSA test, this is significantly lower than the U.S. elder rate of 61 percent. (27, 28)

●

Women aged 40 and older are recommended to get one mammogram each year. Only 54% of American Indian/Alaska Native elder women had their last mammogram within the year. This is significantly lower than the U.S. elder rate of 62 percent. (27-29)

●

American Indians/Alaska Natives are underrepresented in clinical trials. LaVallie et al. reported the factors that increase the willingness to participate were having a lead researcher of Native descent, having a study physician with experience treating American Indians/Alaska Natives, personal experience with the cancer being studied, family support for participation, and belief/hope that the study would result in new treatments. (30)

●

More than 68% of American Indian/Alaska Native women aged 40 and over in California had a mammogram within the past two years, however, 1 in 10 American Indian/Alaska Native women 40 years and older, reported never having a mammogram. (31)

●

Although the inability to speak English constitutes a major barrier for elderly Asian American women when seeking health care, it is further complicated by the fact that many Asian elderly believe the healer is supposed to make a diagnosis without much discussion and with little or no physical contact. Thus, physicians who ask too many questions, request too many tests, or suggest probabilities of outcomes, are likely to lose credibility among these elderly. (32)

Elderly and Cancer

Outcomes ●

It is anticipated that both health insurance and health care services will be less available and accessible for elderly women of color than among elderly non-Hispanic/Latino white women. (5)

●

Racial and ethnic minority elders report lower rates of health care utilization than those by non-Hispanic/Latino whites, despite the greater per capita need for health care services. (5)

●

In general, racial and ethnic elderly minorities covered by Medicare suffer from more illnesses and are more apt to live in poverty. As such, they face greater risk of access problems and financial burdens. (26)

●

Elderly American Indian/Alaska Natives receive health services at lower rates than their counterparts in the general populations. The Indian Health Service discharge rate among the elderly (171.4 per 1000) is half the US rate (344.6 per 1000). (30)

●

Breast cancer is the most common cancer among Native Hawaiian females, with the peak incidence of all cancers occurring among 65- to 74-year olds. (33)

●

Hospice care can alleviate suffering at the end of life for patients with cancer. African Americans/blacks (42.5%) and Hispanics/Latinos (44.5%) were significantly less likely than non-Hispanic/Latino whites (46.5%) to use hospice care. (34)

●

Ten percent of elderly African American/blacks with Medicare coverage report delays in receiving heath care due to cost, along with 7% of Hispanics/Latinos and 5% of nonHispanic/Latino whites. (35)

References 1.

2. 3.

US Census Bureau. Facts for Features. Older Americans Month – May 2010. Available at: http://www.census.gov/ newsroom/releases/archives/facts_for_features_special_editions/ cb10-ff06.html. Accessed January 2011. US Department of Health and Human Services, Office of Women’s Health. Women of Color Health Data Book, 1997. US Census Bureau. Rankings and Comparisons Population and Housing Tables (PHC-T Series). Population Division: Washington, DC, 2000.

4. 5. 6. 7.

10. 11. 12. 13.

14. 15.

16.

17.

18.

19.

20.

US Census Bureau. We the American Elderly. Washington, DC, 1993. Wray, L. Health Policy and Ethnic Diversity in Older Americans: Dissonance or Harmony? West J Med. 1992;157(3):357-61. American Cancer Society. Cancer Facts and Figures: Atlanta, GA, 2002. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2000: Key Indicators of Well-Being. US Government Printing Office: Washington, DC, 2000. Medicare Chartbook: Medicare Beneficiaries. The Henry J. Kaiser Family Foundation. Updated 2010. Available at: http://www.kff.org/medicare/upload/8103.pdf. Accessed January 2011. Centers for Disease Control and Prevention. The National Breast and Cervical Cancer Early Detection Program: Reducing Mortality through Screening. National Center for Chronic Disease Prevention and Health Promotion: Atlanta, GA, 2003. American Cancer Society. Cancer Reference Information: Can Cervical Cancer Be Found Early? Atlanta, GA, 2002. Centers for Disease Control and Prevention. Trends in Screening for Colorectal Cancer, US 1997 and 1999. MMWR. 2001;50:162-66. Kagay CR, Quale C, Smith-Bindman R. Screening Mammography in the American Elderly. Am J Prev Med. 2006;31(2):142-49. Gilligan T, Wang PS, Levin R, Kantoff PW, Avorn J. Racial Differences in Screening for Prostate Cancer in the Elderly. Arch Intern Med. 2004;164(17):1858-64. Centers for Disease Control and Prevention. Breast and Cervical Cancer Screening: At-a-Glance: Atlanta, GA, 2001. Smith RA, von Eschenbach AC, Wender R, et al. American Cancer Society Guidelines for the Early Detection of Cancer: Update of Early Detection Guidelines for Prostate, Colorectal, and Endometrial Cancers. CA Cancer J Clin. 2001;51(1):38-75. Wu ZH, Black SA, Markides KS. Prevalence and Associated Factors of Cancer Screening: Why are so Many Older Mexican American Women Never Screened? Prev Med. 2001;33(4):268-73. Sabatino SA, Coates RJ, Uhler RJ, Breen N, Tangka F, Shaw KM. Disparities in Mammography Use among US Women Aged 40-64 Years, by Race, Ethnicity, Income, and Health Insurance Status, 1993 and 2005. Med Care. 2008;46(7):692-700. Cabeza E, Esteva M, Pujol A, Thomas V, Sánchez-Contador C. Social Disparities in Breast and Cervical Cancer Preventive Practices. Eur J Cancer Prev. 2007;16(4): 372-79. Hodgson DC, Fuchs CS, Ayanian JZ. Impact of Patient and Provider Characteristics on the Treatment and Outcomes of Colorectal Cancer. J Natl Cancer Inst. 2001;93(7):501-15. Ries LAG, Melbert D, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2005, National Cancer Institute. Bethesda, MD.

21. Srinivasan S, Gullermo T. Toward Improved Health: Disaggregating Asian American and Native Hawaiian/Pacific Islander Data. Am J of Public Health. 2000; 90(11):1731-33. 22. Lewis JH, Kilgore ML, Goldman DP, et al. Participation of Patients 65 Years of Age or Older in Cancer Clinical Trials. J Clin Oncol. 2003; 21(7):1383-89. 23. Gross CP, Filardo G, Mayne ST, Krumholz HM. The Impact of Socioeconomic Status and Race on Trial Participation for Older Women with Breast Cancer. Cancer. 2005; 103(3):483-91. 24. American Cancer Society. Cancer Facts and Figures for AfricanAmericans 2002-2003. American Cancer Society: Atlanta, GA, 2003. 25. Hollenbeck BK, Miller DC, Taub D, et al. Aggressive Treatment for Bladder Cancer is Associated with Improved Overall Survival among Patients 80 Years Old or Older. Urology. 2004;64(2):292-97. 26. American Cancer Society. Breast Cancer Facts and Figures. American Cancer Society: Atlanta, GA, 2001. 27. Cancer Screening Practices among American Indian and Alaska Native Elders. Rural Health Facts. Updated 2006. Available at: http://ruralhealth.und.edu/pdf/fs_CancerScreening.pdf. Accessed January 2011. 28. Behavioral Risk Factor Surveillance System. 2005. U.S. Household Survey Data File. Atlanta, GA: CDC. 29. American Cancer Society. Guidelines for the Early Detection of Cancer. Updated July 2010. Available at: http://www.cancer.org/ Healthy/FindCancerEarly/CancerScreeningGuidelines/americancancer-society-guidelines-for-the-early-detection-of-cancer. Accessed January 2011. 30. LaVallie DL, Wolf FM, Jacobsen C, Buchwald D. Barriers to Cancer Clinical Trial Participation among Native Elders. Ethn Dis. 2008;18(2):210-17. 31. Satter DE, Le TM, Gatchell M, Seals BF, Burhansstipanov L, Randall LL. American Indian and Alaska Native Cancer Fact Sheet. UCLA Center for Health Policy Research. 2004. 32. Nguyen GT, Bowman MA. Culture, Language, and Health Literacy: Communicating About Health with Asians and Pacific Islanders. Fam Med. 2007;39(3):208-10. 33. Asian and Pacific Islander American Health Forum. Asian and Pacific Islander National Cancer Survivors Network: Facts on Asians and Pacific Islanders: San Francisco, CA, 2002. 34. Haas JS, Earle CC, Orav JE, et al. Lower Use of Hospice by Cancer Patients Who Live in Minority Versus White Areas. J Gen Intern Med. 2007;22(3):396-99. 35. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2000: Key Indicators of Well-Being. U.S. Government Printing Office: Hyattsville, MD, 2000.

Cancer Facts Children/Adolescents and Cancer

WHO WE ARE

s American children and adolescents under 18 years of age we number 72.3 million, or about 26% of the U.S. population and our numbers are increasing. We have grown from 63.6 million in 1990 representing a 13% increase.(1) Seventeen percent of us are Hispanic and 15% are African American. More than 3% of us belong to Asian and Pacific Islander groups while 1.1% are American Indian/Alaska Natives. (1) About two-thirds of us (68.8%) are non Hispanic/Latino white. Throughout the past 50 years, less

than half of us have lived in “traditional” families where the father was a full-time worker and the mother a full-time homemaker. Currently, a majority of us (70%) live with both parents, but an increasing proportion of us have only one parent in the home. An increasing number of us now live with a grandparent or even nonrelatives including housemates, roommates, and unmarried partners.(2) For every one of us who lives in a “traditional” family, four of us live in “nontraditional” two-parent families.

Causes/Etiology

Screening

●

The cause of most childhood cancers is unknown, although some of these cancers are the result of genetic predisposition. Radiation exposure also contributes to certain types of childhood cancers. Other factors that have been implicated in childhood cancers include infectious diseases, prenatal conditions, environmental pollutants, and use of medications.(5)

●

Cancer during the adolescent and young adult years challenges these young people’s ability to achieve crucial developmental milestones such as establishing autonomy and independence, intimate relationships, and financial independence.(6-8) All racial and ethnic groups with cancer are underrepresented in cancer clinical trials. Only 50% of children with cancer are enrolled into treatment trials.(9)

Disparities

●

Disparities in mortality and survival outcomes for adolescents and young adults may be attributable to limited access to healthcare/higher rates of uninsured and low enrollment in clinical trials.(10, 11)

Almost 13 million of us live in families with incomes below the federal poverty level. Nationwide, 17% of us are living in families that are officially labeled as poor, an increase of 11% since 2000.(3) As African American, Hispanic, and American Indian/Alaska Native children, we experience much higher poverty rates than non Hispanic/ Latino white children. Further, 11.7% of all children (8.7 million) have no health insurance. Among those of us who are poor, 19% of us lack health insurance coverage.(4)

●

Lack of health insurance and family poverty are often insurmountable barriers to adolescents in need of health care services. Non-financial barriers also interfere with the ability of adolescents to get care and contribute to limited frequency of contact and the lack of relationships with providers.(12)

●

Uninsured children in the U.S. are less likely to get appropriate or preventive care.(13)

●

Eligibility restrictions, coupled with barriers to Medicaid enrollment, leave a quarter of low-income children uninsured. (14)

●

From 1975 to 2003 in the United States, Hispanic/Latino children were found to have higher incidence of leukemia, retinoblastoma, osteosarcoma, and germ-cell tumors when compared to non-Hispanic/Latino white children.(15)

●

Florida cancer registry incidence data indicate a 30% increase in incidence of lymphoma in Hispanic/Latino children compared to non-Hispanic white children.(16)

Project Director Nicholas K. Iammarino, PhD, CHES These ICC Cancer Fact Sheets were updated through an educational grant from Ortho Biotech.

Research Assistants Mohammed Ansar Ahmed Prem Ramkumar

●

For lymphomas in general (including the Hodgkin lymphoma and non-Hodgkin lymphoma subtypes), Hispanic/Latino children have higher incidence rates (approximately 30% greater) compared to non-Hispanic/Latino white children.(16)

●

The incidence rate of Burkitt’s lymphoma is higher for Hispanic/Latino children than it is for non-Hispanic/Latino white children, although the increase is less than that observed for either Hodgkin’s lymphoma or non-Hodgkin lymphoma.(16)

●

In general, Hispanic/Latino children in Florida have significantly higher risks of lymphoid leukemia and lymphomas, as well as the Hodgkin’s lymphoma and nonHodgkin lymphoma subtypes, when compared to nonHispanic/Latino white children.(16)

●

Lymphoma incidence rates for Hispanic/Latino children living in Florida are nearly 2 to 3 times higher than those in Texas or California.(16)

●

The incidence of germ cell, trophoblastic, and other gonadal neoplasms is 60% higher among Hispanic/Latino children than among non-Hispanic/Latino white children (13.8 and 11.5 new cases per 100,000 children, respectively).(17)

●

The incidence of lymphoid leukemia is approximately 15% higher among Hispanic/Latino children than among nonHispanic/Latino white children (39.7 and 33.7 new cases per 100,000 respectively).(17) The incidence rate for leukemia, the most common childhood cancer, is approximately 17% higher among Hispanic/Latino children compared with non-Hispanic/ Latino white children (53.7 and 46.2 new cases per 100,000 children, respectively).(17) Leukemia accounts for greater than 40% of all cancers diagnosed in Hispanic/Latino children aged less than 5 years. It also accounts for more than 45% of all cancers diagnosed in Hispanic/Latino children aged 5-9 years, and 31% of all cancers diagnosed in Hispanic/Latino children aged 10-14.(17) Lymphomas and Central Nervous System (CNS) neoplasms comprise 30% of all cancers diagnosed in Hispanic/Latino children aged 10-14.(17, 18)

●

Hispanics/Latinos have the highest acute lymphoblastic leukemia (ALL) rate compared to African American/blacks and non-Hispanic/Latino whites.(19)

●

Incidence rates for childhood leukemia are reported to be higher in California Hispanics/Latinos, but the increase is noted only in children aged 5-14 years.(20)

●

From 1988 to 1994, more than 7,100 cases of childhood cancer were diagnosed in California. More than one-third of the cases were leukemias, and 19% were gliomas; 36% of the total cases were Hispanic/Latino children, 47% were nonHispanic/Latino white, and 7% were African American/ black.(20)

●

Asian and Pacific Islander children show a two-fold increased risk of developing acute nonlymphatic leukemia (ANLL) compared to non-Hispanic/Latino white infants.(20)

●

As a subset of acute nonlymphatic leukemia (ANLL), Asian and Pacific Islander children have an increased risk for developing acute myeloid leukemia (AML) compared to nonHispanic/Latino white infants.(20)

●

Nearly 80% of the ovarian cancers among children and young adults occur among non-Hispanic/Latino whites, approximately 12% occur among African Americans/blacks, and 6% occur among Asian and Pacific Islanders.(21)

●

In each age group, from birth to 24 years, ovarian cancer rates among Hispanic/Latino children and adolescents exceed the rates among non-Hispanic/Latino females. Rates among Hispanic/Latino girls between the ages of birth and 14 years were 42% higher than among non-Hispanic/Latino girls.(21)

●

Among girls from birth to 14 years old, the rate of ovarian cancer is highest among Asian Pacific Islanders (5.7 per million), followed by African Americans/blacks (4.2 per million) and non-Hispanic/Latino whites (3.8 per million).(21)

●

The majority (53-64%) of ovarian cancers diagnosed in children and adolescents are diagnosed at a localized stage compared to less than 20% of tumors in women age 50 years and older.(21)

Children/Adolescents and Cancer

Outcomes ●

Childhood cancers showed some of the largest improvements in cancer survival during the past 20 years, with an absolute survival rate increase of 20% in boys and 13% in girls.(22)

●

Although the incidence of invasive cancer in children has increased slightly over the past 30 years, mortality in this group has declined dramatically for many childhood cancers.(23)

●

Research suggests that adolescents and young adult cancer patients tend to present with more advanced and aggressive diagnoses, and adolescents and young adult patients account for an estimated 2% of all invasive cancer diagnoses compared to 0.75% in childhood cancer patients.(24)

●

An estimated 1.6 million African Americans/blacks who are now under the age of 18 will become regular smokers. About 500,000 of those smokers will die of a smoking-related disease.(25)

●

In Multnomah County, Oregon, cancer is the second leading cause of death among children ages 1-9 who are 16% Hispanics/Latinos, 15% Asian Americans, 14% African American/black, 13% American Indian, and 11% nonHispanic/Latino white.(26)

●

Among children with high risk factors, Hispanic/Latino children with acute lymphoblastic leukemia (ALL) have significantly poorer outcomes than non-Hispanic/Latino white children.(27)

●

African American/black children with acute lymphoblastic leukemia (ALL) have poorer 5 year survival rates than nonHispanic/Latino white children (58% versus 71%).(19)

●

While the median survival period for children with acute lymphoblastic leukemia (ALL) is more than 10 years overall, the 5 year survival rate remains poor for African American/black males under 4 years of age compared to other same aged children (50% versus 82-88%).(19) African American/black and Hispanic/Latino children have worse survival rates and Asian children have better survival rates of acute lymphoblastic leukemia (ALL) when compared to non-Hispanic/Latino white children after adjusting for known risk factors.(27)

Children/Adolescents and Cancer

●

Cancer occurring between the ages of 15 and 30 years is 2.7 times more common than cancer occurring during the first 15 years of life, yet is much less common than cancer in older age groups, and accounts for just 2% of all invasive cancer.(24)

●

For all sites, the 5-year survival rate for childhood cancer is 79%; neuroblastoma, 66%; brain and other nervous system, 73%; bone and joint, 73%; leukemia, 79%; Wilms tumor (kidney), 92%; and Hodgkin lymphoma, 96%.(28)

●

The overall 10-year period survival estimate for the years 1995-99 was 59% for children with all central nervous system (CNS) tumors combined, 73% for children with astrocytoma, 53% for children with ependymoma and 45% for children with primitive neuroectodermal tumors.(29)

●

Non-Hodgkin lymphoma is the third most common childhood malignancy and occurs approximately 1.5 times as often as Hodgkin lymphoma in childhood.(28, 30)

●

From 1992 to 2001, Hispanics/Latinos in the United States did not have a greater lifetime incidence of acute promyelocytic leukemia than non-Hispanic whites, but incidence among Hispanic/Latino children ages 1-19 years was greater than in non-Hispanic/Latino white children ages 1-19.(31)

●

Children with thyroid cancer have higher local and distant disease recurrences with progression-free survival of only 70% at 5 years, mandating life-long surveillance.(32)

References 1.

U.S. Census Bureau. Children and the Households They Live In: 2000. Census 2000 Special Reports. Issued March 2004. Washington, DC. Kreider RM. Living Arrangements of Children: 2004. Current Population Reports, U.S. Census Bureau, Washington, DC. P70-114. U.S. Census Bureau. Current Population Survey Annual Demographic Supplement: Low Income Uninsured Children by State: 1999, 2000, 2001: Washington, DC, 2002. DeNavas-Walt C, Proctor BD, Smith J. Income, Poverty, and Health Insurance Coverage in the United States: 2006. U.S. Census Bureau, Washington, DC.

8. 9.

10.

11. 12. 13.

14.

15.

16.

17.

18.

19.

Cancer Fact Sheet. Department of Health and Human Services Agency for Toxic Substances & Disease Registry. Updated 2010. Available at: http://www.atsdr.cdc.gov/ toxfaqs/index.asp. Accessed January 2011. Abrams AN, Hazen EP, Penson RT. Psychosocial Issues in Adolescents with Cancer. Cancer Treat Rev. 2007;33:622–630. DOI 10.1016/j.ctrv.2006.12.006. Eiser C, Kuperberg A. Psychological Support for Adolescents and Young Adults. In: Bleyer A, Barr RD (eds) Cancer in Adolescents and Young Adults. Springer-Verlag, Berlin, Heidelberg. 2007;365–74. Evan E, Zeltzer LK. Psychosocial Dimensions of Cancer in Adolescents and Young Adults. Cancer. 2006;107(7):1663-71. Sateren W, Trimble J, Brawley O, et al. How Sociodemographics, Presence of Oncology Specialists, and Hospital Cancer Programs Affect Accrual to Cancer Treatment Trials. J Clin Oncol. 2002;20:2109-17. DeAngelo DJ. The Treatment of Adolescents and Young Adults with Acute Lymphoblastic Leukemia. Hematology Am Soc Hematol Educ Program. 2005;123-30. Haase JE, Phillips CR. The Adolescent/Young Adult Experience. J Pediatr Oncol Nurs. 2004;21(3):145-49. Brindis CD, Morreale MC, English A. The Unique Health Care Needs of Adolescents. Future Child. 2003;13(1):117-35. Kaiser Commission on Medicaid and the Uninsured. The Uninsured and Their Access to Health Care. Menlo Park, CA, 2006. Kaiser Commission on Medicaid and the Uninsured. The Uninsured: A Primer - Key Facts about Americans without Health Insurance. Menlo Park, CA, 2006. Howe HL, Wu X, Ries LA, et al. Annual Report to the Nation on the Status of Cancer, 1975-2003, Featuring Cancer Among U.S. Hispanic/Latino Populations. Cancer. 2006;107(8):1711-42. Wilkinson J, Fleming L, MacKinnon J, Voti L, Wohler-Torres B, Peace S, et al. Lymphoma and Lymphoid Leukemia Incidence in Florida Children. Cancer. 2001;91(7):1402-08. U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2004 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2007. Available at: http://wonder.cdc.gov/wonder/help/cancer/uscs_2004.pdf. Accessed January 2011. Peace S, Button J, Trapido E. Cancer Incidence among Hispanic Children in the United States. Rev Panam Salud Publica. 2005;18(1):5-13. McNeil D, Cote T, Clegg L, Mauer A. SEER Update of Incidence and Trends in Pediatric Malignancies: Acute Lymphoblastic Leukemia. Medical and Pediatric Oncology. 2002;39(6):554-57.

20. Reynolds P, Von Behren J, Elkin E. Birth Characteristics and Leukemia in Young Children. Am J Epidemiol. 2002;155: 603-13. 21. Young J, Wu X, Roffers S, Howe H, Correa C, Weinstein R. Ovarian Cancer in Children and Young Adults in the United States 1992-1997. Cancer. 2003;97(10):2694-2700. 22. Annual Report to the Nation Finds Cancer Incidence and Death Rates on the Decline: Survival Rates Show Significant Improvement. Centers for Disease Control Press Release. June 3, 2004. Available at: http://www.cdc.gov/media/ pressrel/r040603b.htm. Accessed January 2011. 23. A Snapshot of Pediatric Cancer. National Cancer Institute. September 2006. Available at: http://www.cancer.gov/aboutnci/servingpeople/pediatricsnapshot.pdf. Accessed January 2011. 24. Bleyer A, O’Leary M, Barr R, Ries LAG (eds): Cancer Epidemiology in Older Adolescents and Young Adults 15 to 29 Years of Age, Including SEER Incidence and Survival: 1975-2000. National Cancer Institute, NIH Pub. No. 065767. Bethesda, MD 2006. 25. American Lung Association. Minority Lung Disease Data, 2000. Available at: http://www.lungusa.org/assets/documents/publications/l ung-disease-data/MLDD_2000.pdf. Accessed January 2011. 26. Multnomah County Health Department. The Health of Multnomah County: A Report on the Health of Multnomah County Residents, Multnomah, OR, 2002. 27. Bhatia S, Sather HN, Heerema NA, Trigg ME, Gaynon PS, Robison LL. Racial and Ethnic Differences in Survival of Children with Acute Lymphoblastic Leukemia. Blood. 2002;100(6):1957-64. 28. Detailed Guide: Cancer in Children. American Cancer Society. Updated 2011. Available at: http://www.cancer.org/Cancer/CancerinChildren/Detailed Guide/index. Accessed January 2011. 29. Arndt V, Kaatsch P, Steliarova-Foucher E, Peris-Bonet R, Brenner H. Up-To-Date Monitoring of Childhood Cancer Long-Term Survival in Europe: Central Nervous System Tumours. Ann Oncol. 2007;18(10):1734-42. 30. Non-Hodgkin Lymphoma. Lymphoma Research Foundation. Updated 2008. www.lymphoma.org/site/ pp.asp?c= chKoI6PEImE&b=1573333. Accessed January 2011. 31. Matasar MJ, Ritchie EK, Consedine N, Magai C, Neugut AI, Eur J. Incidence Rates of Acute Promyelocytic Leukemia Among Hispanics, Blacks, Asians, and Non-Hispanic Whites in the United States. Cancer Prev. 2006;15(4):367-70. 32. Parisi MT, Mankoff D. Differentiated Pediatric Thyroid Cancer: Correlates with Adult Disease, Controversies in Treatment. Semin Nucl Med. 2007;37(5):340-56.

Cancer Facts Rural Poor

WHO WE ARE

e are the rural poor and medically underserved living all across the U.S. We represent approximately 7.3 million individuals (or 15.1%) of the rural population in America compared to our 12.5% urban poor counterparts. In fact, our rural poverty rates have always been higher than those living in urban areas and are also considered “persistent”, meaning a consistently high poverty rate for more than 40 years.(1) This is due to many factors such as our isolation and sparse population, our limited economic opportunities, and our lower educational levels among our working adult population. The majority of us are nonHispanic/Latino white (66.3%) compared to those living in urban

areas (40.4%).(1) We tend to live in the South which has the highest poverty rate at 13.8 percent.(2) In the Appalachia region alone, we number more than 22 million people in 404 counties in 13 states between Southwestern New York and Mississippi. Central Appalachia includes the defined geographic area of West Virginia, and parts of Kentucky, Tennessee, Virginia, and Ohio where a higher proportion of the almost entirely non-Hispanic/Latino white, largely rural population is poor. The Appalachian region has traditionally experienced higher poverty rates, lower education levels, and limited access to health care compared to the nation as a whole. Approximately 65% of Appalachian

Causes/Etiology ●

Women who live in Appalachia are at higher risk for cervical cancer than other U.S. women and, in particular, the rate of cervical cancer mortality in Appalachian Kentucky is the highest of the 13 Appalachian states, and about 50% higher than nationwide rates.(4,5)

●

Research suggests that lung cancer mortality rate is higher in the coal-mining region of Appalachia. Risk factors such as smoking, mining, and also the correlation of poverty and low education all contribute to this data.(6)

●

Major sources of employment in rural areas generally include agriculture, mining, and forestry, with a high potential for work-related injuries which raise the risk for cancer development.(7)

counties are rural: 42% of the region’s residents live in these rural counties. Furthermore, 108 of the 404 counties are categorized as distressed or severely distressed. As rural individuals, we tend to be older, poorer, less educated, and more likely to be uninsured than our urban counterparts. As such, we have higher rates of chronic illness and disabilities and are overall in poorer health than our urban neighbors. Generally, we have less contact and fewer visits with physicians and, lower levels of preventive care. While poverty or low socioeconomic status has not been directly related to a higher incidence of cancer, research has shown that poverty has an adverse effect on cancer survival rates.(3)

●

Appalachians share similar values in terms of importance of family, religion, and home as do American Indian and Hispanic populations. Further, they also share problems such as low socioeconomic status, lack of access to health care, and low educational attainment.(8)

●

Access issues for Appalachians include physicians who tend to leave for urban settings after short periods and who are not native to the area. This is further exacerbated with difficulty in understanding them and the likelihood of cultural miscommunication.(9)

●

Appalachian geography isolates many smaller communities from cities and healthcare resources. Mountain chains, valleys and rivers often separate small communities and inhibit transportation to health facilities.(10)

Project Director Nicholas K. Iammarino, PhD, CHES These ICC Cancer Fact Sheets were updated through an educational grant from Ortho Biotech.

Research Assistants Mohammed Ansar Ahmed Prem Ramkumar

Screening ●

Conflicting guidelines, time constraints, and perceptions that patients do not value prevention were reported as barriers to cancer screening by rural Appalachian patient care providers.(11)

●

Hall et al. reported that the prevalence of recent mammography among women in Appalachia, which is largely rural, is lower than among other women in the United States.(12)

●

Rural residence, geographic isolation, poverty, unemployment, lack of education, lack of child care services, and attitudinal and cultural factors may pose barriers to cancer screening among Appalachian women.(13)

●

Breast cancer has more often been diagnosed at a late stage in rural Appalachia than elsewhere in the United States; this is mainly associated with an absence of screening.(14, 15)

●

A study conducted of Appalachian women in West Virginia, reported that cost, fear, and embarrassment were identified as the top barriers to breast and cervical cancer screening.(16) Among Central Appalachian women, barriers to cervical cancer screening include fear of being subjected to medical scrutiny because of obesity or being a smoker, inadequate health care access, long travel time to medical services and clinic schedules that do not accommodate working women.(17)

●

The disproportionately high cancer-related mortality rates still persist even though the economic state of many Appalachian counties have improved, recent findings demonstrate higher rates for selected types of cancers such as cervical, colorectal and lung.(22-24)

●

Recent studies have identified higher rates of cancer and, in particular, cervical cancer; heart disease; and premature mortality in the Appalachian regional population.(25)

●

Rural areas have the highest death rates for children and young adults with a 20% higher increase in lung and liver cancer compared to metropolitan areas.(26)

●

Elderly Americans who live in low income, rural area have a 17%-39% higher chance of death after surgeries mainly due to the quality of care at lower end rural hospitals.(27)

●

Geographical differences are seen in a pattern of excessive prostate cancer among African American/black males living in rural Southeastern United States, with a much greater prevalence among low socio-economic African American/blacks in that area.(28)

●

Halverson’s analysis reported that besides poor non Hispanic/White Appalachians, mortality rates for African American/blacks who also live in Appalachia exceeded national African American/black mortality rates.(29)

Patient/Provider Communication ●

●

Stitzenberg et al. reported the distance a patient has to travel to see the doctor who diagnoses their melanoma, the more likely they are to have thicker and more lethal skin cancer at the time of diagnoses.(18) Rural surgeons are often uneasy when their outcomes are compared with those of urban surgeons, largely because they perceive that rural patients typically present with worse disease.(19, 20)

Outcomes ●

The lung cancer rate for Appalachian men was nearly 25% higher than the rate for men living in the rest of the US. The lung cancer rate for Appalachian women was 8% higher than the rate for women in the rest of the U.S.(30)

●

From 2001-2003, Appalachian men and women had the highest incidence rates in all sites combined (415 per 100,000) when compared to the U.S. general population (398 per 100,000).(30)

Disparities ●

Rural residents who are older, represent minorities, and are of low-income status use fewer medical screenings and early detection options available, leading to late diagnosis and increasing the mortality rate.(21)

Rural Poor and Cancer

●

Couto et al. reported approximately 13% of Appalachians are considered to be medically indigent. The rate of mammography among Appalachian women was 3.2% lower than the national rate, and the Papanicolaou (Pap) test rate was 2.5% lower.(12, 31)

Rural women in the United States have higher cervical cancer incidence rates. Among older women (aged 45–80 years) in whom half of cervical cancers occur, geographic differences largely disappear after controlling for poverty and race.(32)

The cancer prevalence and mortality rates for the Appalachian region is much higher in rural Appalachia than all of Appalachia itself, with 176.3 per 100,000 compared to 173.1 to 100,000 of total Appalachia. It is also significantly higher than the national cancer death rate of 166.7 per100,000.(33)

10.

11.

References 1.

Rural Realities. At the Razor’s Edge: Building Hope for America’s Rural Poor. Updated 2006. Available at: http://ruralsociology.org/StaticContent/Publications/Rural realities/pubs/RuralRealities1-1.pdf. Accessed February 2011. DeNavas-Walt C, Proctor BD. Income, Poverty, and Health Insurance Coverage in the United States: 2006 U.S. Department of Commerce Economics and Statistics Administration US Census Bureau. Updated August 2007. Available at: http://www.census.gov/prod/2007pubs/p60233.pdf. Accessed February 2011. Underlying Socioeconomic Factors Influencing Health Disparities in the Appalachian Region Appalachia Regional Commission. Available at: http://www.arc.gov/assets/ research_reports/SocioeconomicFactorsInfluencingHealth DisparitiesinAppalachianRegion5.pdf. Accessed February 2011. Huang B, Wyatt SW, Tucker TC, Bottorff D, Lengerich E, Hall HI. Cancer Death Rates – Appalachia 1994–1998. MMWR. 2002;51:527–29. Hall HI, Rogers JD, Weir HK, Miller DS, Uhler RJ. Breast and Cervical Carcinoma Mortality among Women in the Appalachian Region of the US 1976–1996. Cancer. 2000; 89:1593–1602.

Rural Poor and Cancer

12.

13.

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15.

16.

17.

18.

Hendryx M, O’Donnell K, Horn K. Lung Cancer Mortality is Elevated in Coal-Mining Areas of Appalachia. Lung Cancer. 2008. doi:10.1016/j.lungcan.2008.02.004. University of Pittsburgh Center for Rural Health Practice. Bridging the Health Divide: The Rural Public Health Research Agenda. 2004:16-20. Marshal CA. American Indian and Hispanic Populations Have Cultural Values and Issues Similar to Those of Appalachian Populations. Prev Chron Dis. 2007;4(3):1-2. Documet PI, Green HH, Adams J, et al. Perspectives of African American, Amish, Appalachian and Latina Women on Breast and Cervical Cancer Screening: Implications for Cultural Competence. J Health Care Poor Underserved. 2008;19:56-74. Behringer G, Friedel GH, Dorgan KA, et al. Understanding the Challenges of Reducing Cancer in Appalachia: Addressing a Place-Based health Disparity Population. California J Health Promot. 2007;5;40-49. Shell R, Tudiver R. Barriers to Cancer Screening by Rural Appalachian Primary Care Providers. J Rural Health. 2006;20(4):268-73. Hall HI, Uhler RJ, Coughlin SS, Miller DS. Breast and Cervical Cancer Screening among Appalachian Women. Cancer Epidemiol Biomark Prev. 2002;11(1):137-42. U.S. Department of Health and Human Services. Healthy People 2010 (Conference Edition, in Two Volumes). Washington, DC 2000. Lengerich EJ, Tucker T, Powell RK, et al. Cancer Incidence in Kentucky, Pennsylvania, and West Virginia: Disparities in Appalachia. J Rural Health. 2005;21(1):39-47. Taplin SH, Ichikawa L, Yood MU, et al. Reason for LateStage Breast Cancer: Absence of Screening or Detection, or Breakdown in Follow-Up? J Natl Cancer Inst. 2004;96(20):1518-27. Lyttle NL, Stadelman K. Assessing Awareness and Knowledge of Breast and Cervical Cancer among Appalachian Women. Prev Chronic Dis. 2006;3(4):A125. Schoenberg NE, Hoopenhayn C, Christian A, et al. An InDepth and Updated Perspective on Determinants of Cervical Cancer Screening Among Central Appalachian Women. Women and Health. 2006;42(2):89-115. Stitzenberg KB, Thomas NE, Dalton K, et al. Distance to Diagnosing Provider as a Measure of Access for Patients with Melanoma. Arch Dermatol. 2007;143(8):991-98.

19. Finlayson SRG. Surgery in Rural America, Surg Innov. 2005;12:229–305. 20. Heneghan SJ, Bordley J, Dietz PA, et al. Comparison of Urban and Rural General Surgeons: Motivations for Practice Location, Practice Patterns, and Education Requirements. J Am Coll Surg. 2005; 201:732–36. 21. Centers for Disease Control and Prevention. 2002 Program Fact Sheet. Comprehensive Cancer Control. Updated 2003. Available at: http://www.cdc.gov/cancer/ncccp/about.htm. Accessed August 2011. 22. Appalachian Regional Commission. 2004. Cancer Mortality in Appalachia. An Analysis of Disparities in Health Status and Access to Health Care in the Appalachian Region: An ARC Report. Available at: http://www.arc.gov/research/ researchreportdetails.asp?REPORT_ID=82. Accessed February 2011. 23. Armstrong LR, Thompson T, Hall HI, Coughlin SS, Steele B, Rogers JD. Colorectal Carcinoma Mortality Among Appalachian Men and Women, 1969–1999. Cancer. 2004;101, 2851–58. 24. Bluegrass Coalition for Cancer Screening & Kentucky Medical Association Cancer Committee. Colorectal Cancer Facts. J Ky Med Assoc. 2005;103,118. 25. Behringer B, Friedell GH. Appalachia: Where Place Matters in Health. Updated 2006. Available at: http://www.cdc.gov/Pcd/issues/2006/oct/06_0067.htm. Accessed February 2011. 26. University of Pittsburgh Center for Rural Health Practice. Bridging the Health Divide: The Rural Public Health Research Agenda. 2004:16-20. 27. Geller BM, Skelly JM, Dorwaldt AL, Howe KD, Dana GS, Flynn BS. Increasing Patient/Physician Communications about Colorectal Cancer Screening in Rural Primary Care Practices. Medical Care. 2008;46(9):36-44.

28. National Cancer Institute. Health Disparities in Cancer. Available at: http://www.cancer.gov/cancertopics/ disparities. Accessed February 2011. 29. Halverson JA, Ma L, Harner EJ. An Analysis of Disparities in Health Status and Access to Health Care in the Appalachian Region. Washington DC: Appalachian Regional Commission. 30. Wingo PA, Tucker TC, Jamison PM, et al. Cancer in Appalachia, 2001-2003. Cancer. 2008;112(1):181-92. 31. Couto RA, Simpson NK, and Harris G. Sowing Seeds in the Mountains: Community-Based Coalitions for Cancer Prevention and Control. National Institutes of Health. National Cancer Institute; Bethesda: 2004. 32. American Cancer Society. Cancer Facts and Figures. Atlanta; 2005. 33. Gosschalk A, Carozza S. Cancer In Rural Areas. Available at: http://www.srph.tamhsc.edu/centers/rhp2010/04Volume1 cancer.pdf. Accessed February 2011.

Cancer Facts Hispanics/Latinos and Cancer

WHO WE ARE

e are called “Hispanic” or sometimes “Latino” to describe our ethnic background. However, as a population we are more accurately referred to as a mosaic of cultures. In reality, the various Hispanic subgroups reflect profound differences in ethnicities, cultures, and origins, and have remarkably few characteristics in common. For example our population covers the racial spectrum; as Hispanics we can be White, African American, Asian or Pacific Islander, or Native American. Moreover, our diversity extends to nationality, customs, heritage, lifestyles, and socioeconomic status. While

similarities among us do exist, particularly in language (Spanish) and religion (Catholic), we have deeply embedded dissimilarities in background and life experiences that influence our health. In practice, this means that one should use caution in making broad generalizations about the Hispanic/Latino population. In 2009, Hispanics/Latinos numbered 48.5 million and made up 16% of the population.(1) By 2050, we will represent almost a quarter of the country’s population (over 100 million).(1) Yet, in 2004, the median income for our Hispanic households was $36,000, which was considerably

Causes/Etiology ●

The underuse of adjuvant therapy is evidenced in minority women diagnosed with early-stage breast cancer. In a large study of women in New York City, this treatment was underused in 23% of Hispanic/Latino women, compared to only 16% of non-Hispanic/Latino white women.(3)

●

Hispanic patients are less likely to receive surgical resections for early-stage lung cancer than non-Hispanic/Latino whites.(4)

●

Latinos are more likely to undergo lung resection at lowvolume hospitals, after controlling for patient and hospital factors. In addition, hospital volume is inversely associated with inpatient mortality, suggesting a disparity that may not be accounted for by racial concentration or limited hospital choice.(5)

●

Lesion thickness is the most important predictor of prognosis in melanoma patients. An analysis of melanoma incidence and mortality found that Hispanics/Latinos had a larger proportion of thick lesions than thin lesions. Only 43.9% of invasive melanomas in Hispanic/Latino males were less than 0.75 mm at diagnosis, compared to 53.7% of those in nonHispanic/Latino white males.(6)

lower than the $48,000 median income for our non-Hispanic/Latino white counterparts. In the same year, our poverty rates were over three times higher (22% vs. 9%) when compared to non-Hispanic/Latino whites. In 2006, only 2% of the Hispanic population, 25 and older, completed a bachelor’s degree or higher.(2) Nearly two-thirds of all Hispanics/ Latinos in the U.S. are of Mexican origin (62.5%) and 9.6% of Puerto Rican origin, while people of Cuban origin, Central and South American origin, and other Hispanics/Latinos each account for 4.3%, 14.3% and 6.6%, respectively.(2)

●

A known risk factor for colorectal cancer is not consuming enough fruits and vegetables. Consumption of fruits and vegetables is particularly low among Latino men, with only 5-19% reporting consuming three or more servings of vegetables per day.(7)

●

The increased incidence of gastric and liver cancer among Hispanics/Latinos may be partially explained by an increased risk of exposure to certain infectious agents such as Helicobacter (H. pylori) and the Hepatitis C virus.(8)

Screening ●

A national cancer survey found that only 53.5% of Hispanic/ Latino men were aware of the prostate-specific antigen (PSA) screening test for prostate cancer. This is a significantly lower awareness than for non-Hispanic/Latino white men (75.4%).(9)

●

Since Medicare began reimbursing colonoscopies for the average-risk population, disparities in screening rates between Hispanics/Latinos and non-Hispanic/Latino whites have increased, while disparities in screening rates for nonHispanic/Latinos whites and African Americans have been reduced.(10)

Project Director Nicholas K. Iammarino, PhD, CHES These ICC Cancer Fact Sheets were updated through an educational grant from Ortho Biotech.

Research Assistants Mohammed Ansar Ahmed Prem Ramkumar

●

In 2003, 66.1% of Hispanic/Latino women aged 40 and older had regular screening mammograms compared to 70.8% of non-Hispanic/Latino whites.(11)

●

From 2000-2003, of the 74.7% of Hispanic/Latina women aged 18 and older who had a pap smear, 64.4% were uninsured, compared to 80.2% of non-Hispanic/Latina whites who had a pap smear of whom 59.3% were uninsured.(11)

●

Lower acculturated Hispanic/Latino women are less likely to ever have received a Pap smear screening.(12)

●

Hispanic/Latino women, who speak mostly Spanish and are not up-to-date with cervical cancer screening guidelines, are less likely to receive a recommendation for a Pap smear compared to those who are highly English proficient.(13)

●

In a recent study of skin cancer awareness among high school students, Hispanic/Latino students were less aware than their non-Hispanic/Latino white peers of skin self-examination. Furthermore, they were also less likely than non-Hispanic/ Latino white students to wear sunscreen, sun-protective clothing, and perceived themselves to be at lower risk for skin cancer than non-Hispanic/Latino white students.(14)

Disparities ●

The incidence of thick (>1.5 mm) melanomas is increasing at a higher rate among Hispanics/Latinos compared to nonHispanic/Latino whites. For Hispanic/Latino males, the annual increase is 15.4% compared to 11.6% among nonHispanic/Latino white males. For Hispanic/Latino females, the incidence of thick tumors is increasing at a rate of 8.9% per year as opposed to only 0.7% for non-Hispanic/Latino white females.(6)

●

Hispanic/Latino and African American/black women are less likely to be diagnosed with early-stage breast cancer than non-Hispanic/Latino white women.(19)

Patient/Provider Communication ●

In a survey of Latinas and non-Latinas referred for colposcopy, Latinas were significantly more likely to report fear of test results or an inability to communicate with their providers in Spanish as barriers to obtaining screening Pap testing.(15)

●

Women living below the poverty line are more likely to be positive for high-risk serotypes of the human papillomavirus (HPV), the causative organism for cervical cancer. Among these women, Mexican American ethnicity was most associated with increased prevalence of HPV.(20)

●

Compared to non-Hispanic/Latino white physicians, Latino physicians were significantly less involved in clinical trials and found less value in them. This in turn, may influence their decision to refer patients to be enrolled in clinical trials.(16)

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Among women diagnosed with ovarian cancer, Hispanic/Latino women are less likely than nonHispanic/Latino white women to receive recommended comprehensive surgery.(21)

●

Women who report not speaking English well have lower rates of screening for breast and cervical cancer. Moreover, these differences are not accounted for by being native to the U.S., having different social or demographic factors, and/or the length of residence in the U.S., which suggests a communication barrier to access.(17)

In a large retrospective analysis of melanoma patients, Hispanic/Latino patients were significantly more likely to have metastases at the time of diagnosis (16%) than nonHispanic/Latino white patients (9%).(22)

●

Cervical cancer incidence is the highest among Hispanic/ Latino women when compared to all other ethnic groups. In 2004, the incidence rate among Hispanics/Latinos was 13.8 per 100,000 compared to 8.5 among non-Hispanic/Latino whites.(23-25)

●

The probability of having a screening mammogram is greater in women who have personal physicians, who seek health care at their physician’s offices, and who have health care coverage. Hispanic/Latino women are less likely than nonHispanic/Latina white women to have these protective factors.(18)

Hispanics/Latinos and Cancer

●

Hispanics have a higher age-specific mortality rate from skin cancer than non-Hispanic/Latino whites aged 45 years and younger.(26)

●

In a survey to determine prostate cancer knowledge among uninsured men, Hispanic/Latino men were more likely to score lower than other ethnic populations.(27)

●

Hispanic/Latino women presenting with breast cancer are more likely to have Stage IV disease, to have poorly differentiated tumors, larger tumors, and to have estrogen receptor-negative tumors compared to non-Hispanic/Latino white women. These factors all portend a poorer prognosis.(28)

Outcomes ●

●

The five most common types of cancers by incidence in Hispanic/Latino men are prostate, colon and rectum, lung and bronchus, urinary bladder, and non-Hodgkin lymphoma. The five most common cancers causing death in Hispanic/ Latino men are lung and bronchus, prostate, colon and rectum, liver and intrahepatic bile duct, and pancreas.(25) The five most common types of cancers by incidence in Hispanic/Latino women are breast, colon and rectum, lung and bronchus, corpus and uterus, and non-Hodgkin lymphoma. The five most common cancers causing death in Hispanic/Latino women are breast, lung and bronchus, colon and rectum, pancreas, and ovarian.(25) The incidence rate of gastric cancer in Hispanic/Latino men (17.8 per 100,000) and women (10 per 100,000) when compared with non-Hispanic/Latino white men (10.8) and women (5.0) is higher.(25) The incidence rate of liver and bile duct cancer in Hispanic/Latino men (13.5 per 100,000) and women (5.8 per 100,000) is higher than that of non-Hispanic/Latino white men (7.2 per 100,000) and women (2.9 per 100,000).(25) The mortality rate for cervical cancer among Hispanic/Latino women is 3.3 per 100,000 compared to 2.6 per 100,000 for women of all races.(25)

Hispanics/Latinos and Cancer

●

The incidence of esophageal and gastric cancer differs by histology between Hispanics/Latinos and other ethnicities. The incidence of squamous cell carcinoma is 48% higher among Hispanic/Latino men than among nonHispanic/Latino white men, and the incidence of cardia adenocarcinoma was 20% higher among Hispanic/Latino women than among non-Hispanic/Latino white women. (29)

●

In a study of adults over 50 years old, the rates of Hispanics/Latinos reporting sigmoidoscopy or colonoscopy within the past five years was only 27.9%, the lowest of all the ethnic groups studied compared to non-Hispanic/Latino whites (48.0%), African Americans/blacks (32.8%), Asian Americans (33.3%), and “other” (33.3%). (30)

●

Among Mexican American and Puerto Rican women, cervical cancer incidence is two to three times higher than in nonHispanic/Latino white women. (31)

References 1.

U.S. Census Bureau. State and County QuickFacts 2009. Updated August 2010. Available at: http://quickfacts.census.gov/qfd/states/00000.html. Accessed November 2010. U.S. Census Bureau. The American Community-Hispanics 2004. Available at: http://www.census.gov/prod/2007pubs/acs-03.pdf. Accessed October 2010. Bickell NA, Wang JJ, Oluwole S, et al. Missed Opportunities: Racial Disparities in Adjuvant Breast Cancer Treatment. J Clin Oncol. 2006;24(9):1357-62. Wisnivesky JP, McGinn T, Henschke C, Hebert P, Iannuzzi MC, Halm EA. Ethnic Disparities in the Treatment of Stage I Non-Small Cell Lung Cancer. Am J Respir Crit Care Med. 2005;171(10):1158-63. Neighbors CJ, Rogers ML, Shenassa ED, et al. Ethnic/Racial Disparities in Hospital Procedure Volume for Lung Resection for Lung Cancer. Med Care. 2007;45(7):655-63. Cockburn MG, Zadnick J, Deapen D. Developing Epidemic of Melanoma in the Hispanic Population Of California. Cancer. 2006;106(5):1162-68.

8. 9. 10.

11. 12.

13.

14.

15.

16.

17.

18.

19.

20.

Ramirez AG, Suarez L, Chalela P, et al. Cancer Risk Factors among Men of Diverse Hispanic or Latino Origins. Prev Med. 2004;39(2):263-69. Jemal A, Murray T, Ward E, et al. Cancer Statistics 2005. CA: Cancer Journal for Clinicians. 2005;55:10-30. McFall SL. Use and Awareness of Prostate Specific Antigen Tests And Race/Ethnicity. J Urol. 2007;177(4):1475-80. Shih YC, Zhao L, Elting LS. Does Medicare Coverage of Colonoscopy Reduce Racial/Ethnic Disparities in Cancer Screening among the Elderly? Health Aff. 2006;25(4):115362. American Cancer Society. Cancer Facts and Figures for Hispanic/Latinos, 2006-2008. Atlanta, Ga: 2006. Shah M, Zhu K, Wu H, Potter J. Hispanic Acculturation and Utilization of Cervical Cancer Screening in the U.S. Prev Med. 2006;42(2):146-49. De Alba I, Sweningson JM. English Proficiency and Physicians’ Recommendation of Pap Smears among Hispanics. Cancer Detect Prev. 2006;30(3):292-96. Fangchao M, Collado-Mesa F, Hu S, Kirsner RS. Skin Cancer Awareness and Sun Protection Behaviors in White Hispanic and Non-White Hispanic High School Students in Miami, Florida. Arch of Dermatol. 2007;143(8):983-88. Del Carmen M, Findley M, Muzikansky A, et al. Demographic, Risk Factor, and Knowledge Differences Between Latinas and Non-Latinas Referred to Colposcopy. Gynecol Oncol. 2007(1);104:70-76. Ramirez AG, Wildes K, Talavera G, Nápoles-Springer A, Gallion K, Pérez-Stable EJ. Clinical Trials Attitudes and Practices of Latino Physicians. Contemp Clin Trials. 2008 Jul;29(4):482-92. Jacobs EA, Karavolos K, Rathouz PJ, Ferris TG, Powell LH. Limited English Proficiency and Breast and Cervical Cancer Screening in a Multiethnic Population. Am J of Public Health. 2005;95(8):1410-16. Aldridge ML, Daniels JL, Jukic AM. Mammograms and Healthcare Access Among US Hispanic and Non-Hispanic Women 40 Years and Older. Fam Community Health. 2006;29(2):80-88. Lantz PM, Mujahid M, Schwartz K, et al. The Influence of Race, Ethnicity, and Individual Socioeconomic Factors on Breast Cancer Stage at Diagnosis. Am J Public Health. 2006;96(12):2173-78. Kahn JA, Lan D, Kahn RS. Sociodemographic Factors Associated with High-Risk Human Papillomavirus Infection. Obstet Gynecol. 2007;110(1):87-95.

21. Goff BA, Matthews BJ, Larson EH, et al. Predictors of Comprehensive Surgical Treatment in Patients with Ovarian Cancer. Cancer. 2007;109:2031-42. 22. Hu S, Soza-Vento RM, Parker DF, et al. Comparison of Stage at Diagnosis of Melanoma Among Hispanic, Black, and White Patients in Miami-Dade County, Florida. Arch Dermat. 2006;142(6):704-08. 23. Detailed Guide: Cervical Cancer What Are the Key Statistics about Cervical Cancer? American Cancer Society. Available at: http://www.cancer.org/Cancer/CervicalCancer/ DetailedGuide/cervical-cancer-key-statistics. Accessed October 2010. 24. Comparing Cervical Cancer by Race and Ethnicity. Center for Disease Control. Available at: http://www.cdc.gov/ cancer/cervical/statistics/race.htm. Accessed October 2010. 25. Ries LAG, Melbert D, Krapcho M, et al., editors. SEER Cancer Statistics Review, 1975–2004. National Cancer Institute. Based on November 2006 SEER data submission. Available at: http://seer.cancer.gov/csr/1975_2007/ index.html. Accessed October 2010. 26. Wong M, Tagawa T, Hsieh HJ, Shapiro MF, Boscardin WJ, Ettner SL. Differences in Cause-Specific Mortality Between Latino and White Adults. Med Care. 2005;43(10):1058-62. 27. Deibert CM, Maliski S, Kwan L, Fink A, Connor SE, Litwin MS. Prostate Cancer Knowledge among Low Income Minority Men. J Urol. 2007;177(5):1851-55. 28. Watlington AT, Byers T, Mouchawar J, et al. Does Having Insurance Affect Differences in Clinical Presentation Between Hispanic and Non-Hispanic White Women with Breast Cancer? Cancer. 2007;109(10):2093-99. 29. Wu X, Chen VW, Andrews PA, Ruiz B, et al. Incidence of Esophageal and Gastric Cancers Among Hispanics, NonHispanic Whites and Non-Hispanic Blacks in the United States: Subsite and Histology Differences. Cancer Causes Control. 2007;18(6):583-93. 30. Vlahov D, Ahern J, Vazquez T, et al. Racial/Ethnic Differences in Screening for Colon Cancer: Report from The New York Cancer Project. Ethn Dis. 2005;15(1):76-83. 31. Ramirez, A. G., & Suarez, L. Hispanic Cultures. In L. Breslow (Ed.), Encyclopedia of Public Health New York, NY: Macmillan Reference USA – Gale Group, 2001; 2:565-567.

Cancer Facts Native Hawaiians/Pacific Islanders and Cancer

WHO WE ARE

s Native Hawaiians and Pacific Islanders of Polynesian, Micronesian and Melanesian ancestry, we total only 0.1 percent of the U.S. population. Our small subgroup includes more than 25 diverse peoples with distinct variations in historical backgrounds, languages, and cultural traditions. Three of our largest Pacific Islander groups make up about three-fourths of the total Pacific Islander population under U.S. jurisdiction. These groups – Native Hawaiians (with over 100,000 people), Samoans, and Guamanians – together account for 74% of our Pacific Islander population. (1) Besides those living in Hawaii and the continental U.S., the rest of us reside in areas of the Pacific, including the six U.S. associated Pacific Island jurisdictions: Guam, American Samoa, the Commonwealth of the Northern Mariana Islands, the Republic of the Marshall Islands, the Republic of Belau, and the Federated States of Micronesia that comprise the four

states of Chuuk, Yap, Kosrae and Pohnpei.(2) Not all of us have chosen to remain in our native homelands. Population forecasts suggest that while the Native Hawaiian population continues to steadily increase, the population of Native Hawaiians in Hawaii is slowly decreasing due to the increasing cost of living and limited economic opportunities. We have migrated in significant numbers to California, Washington, Texas, New York, Florida, and Utah. (2) As an aggregate group, Native Hawaiians and Pacific Islanders remain socio-economically disadvantaged and underserved in access to health and social services. This is a significant and common factor in the disparity among U.S. groups with higher mortality and lower survival rates from cancer. In addition, Pacific Islanders have significantly elevated rates of health-related high-risk behaviors such as smoking, high consumption of alcohol, and obesity,

Causes/Etiology ●

Among people who smoke less than 30 cigarettes per day, Native Hawaiians are more likely to develop lung cancer than members of other ethnic groups, with exception to African Americans.(4, 5)

●

Native Hawaiian and Filipino women are likely to develop breast cancer at an earlier age than women of other ethnic groups. They are also more likely to be diagnosed at a later stage, more likely to have markers of more aggressive cancer, and more likely to die from the disease compared to other ethnic groups.(6)

as well as diets that are high in calories, cholesterol saturated fat, salt, and protein. Other factors contributing to significant health barriers for us include decreased access to, or lack of, cancer prevention and control programs, the inability or lack of cancer prevention and education programs to effectively disseminate information and treatment to our populations, inadequate data collection, and the lack of cultural sensitivity on the part of non-indigenous health care professionals.(3) With the exception of Native Hawaiians residing in Hawaii, we have little in the way of systematic data collection on cancer incidence and mortality for the remainder of us who live in the other Pacific islands and our cancer surveillance and databases are rudimentary at best. Because our surveillance and health infrastructure are often lacking, our cancer burden remains unknown or unstable due to small numbers. (3)

●

In a recent study, researchers found that 34% of Native Hawaiian men smoked, compared with 23% of nonHispanic/Latino white men in Hawaii, and that 28% of Native Hawaiian women smoked, compared to 16% of nonHispanic/Latino white women in Hawaii.(7)

●

In the Republic of the Marshall Islands, cancer is the second leading cause of death, possibly as a consequence of previous nuclear testing in the area. The risk is estimated to be 9% above the natural baseline.(8)

Project Director Nicholas K. Iammarino, PhD, CHES These ICC Cancer Fact Sheets were updated through an educational grant from Ortho Biotech.

Research Assistants Mohammed Ansar Ahmed Prem Ramkumar

Screening ●

Breast carcinoma is the number one cause of cancer-related mortality among Asian American and Pacific Islander women, yet these women have the lowest cancer screening and early detection rates of all ethnic groups.(9)

●

In a recent study, Native Hawaiian women aged 45-75 had significantly lower annual and biennial mammography testing compared to non-Hispanic/Latina white women.(10)

●

In Chuuk State, it is estimated that approximately 500 Pap smears are done each year, reaching less than 5% of the 12,400 women over 20 years of age who are eligible for such screening.(11)

●

In 2002, Guam reported only 29% of men over the age of 40 reported undergoing a prostate-antigen screening (PSA) test compared to 54% of the U.S. general population. Furthermore, only 13% of adults over the age of 50 had a fecal occult blood test [FOBT] in the past 2 years compared to 30% in the U.S., and 31% of adults aged 50+ had a sigmoidoscopy or colonoscopy versus 49% in the U.S.(12,13) Very limited cancer control research has been conducted on Tongans even though they are the fourth largest Pacific Islander group in the United States. The only study to evaluate use of cancer prevention services found extremely low rates of mammography screening in a convenience sample of Tongan women.(14)

Patient/Provider Communication ●

As recently as 2003, the Pacific Island’s only oncologist resided in Guam.(13)

●

Cancer burden in Hawaii is impacted by lack of regular physical activity, poor diet, and most importantly tobacco use.(15)

●

The most recent Hawaii Behavior Risk Factor Surveillance System (BRFSS) data suggest that over 720,000 adults eat fewer than five servings of fruits and vegetables per day, more than half of this number do not engage in regular physical activity and are overweight, and 189,000 are smokers.(15)

●

As of 2003, hospitals in the US Associated Pacific could not offer clinical treatment trials because they did not meet the criteria for conducting trials.(16)

●

Breast cancer is the most common cancer among Samoan women. In regional surveys, 42% of Samoan women 40 years and older had never heard about mammography. For Samoan women, important predictors for obtaining a mammogram include access to care, knowledge about risk factors and screening guidelines, psychosocial factors, and culturespecific beliefs.(26-28)

Disparities ●

Among Native Hawaiian women in Hawaii, 123 of every 100,000 deaths were from breast, stomach, cervical or lung cancer, compared to the 82 of every 100,000 deaths for nonHispanic/Latino white women.(7)

●

Native Hawaiians have one of the highest lung cancer mortality rates compared to other ethnic groups in the United States.(15)

●

Pacific Islanders have a higher incidence of cancer of the stomach, liver, and intrahepatic bile duct than any other ethnic group. Pacific Islander men have a higher mortality rate from liver and bile duct cancer compared to nonHispanic/Latino whites.(24, 25)

Outcomes ●

Breast, stomach, and lung cancer deaths occurred in Native Hawaiian men at a rate of 145 for every 100,000 deaths, compared to the 117 for every 100,000 deaths in nonHispanic/Latino white men.(7)

●

Native Hawaiians have the highest incidence rates of breast and lung cancer and highest mortality from breast, lung, and colon cancer of any ethnic group in the state of Hawaii.(17)

Native Hawaiians/Pacific Islanders and Cancer

●

Native Hawaiian men with testicular cancer are more likely to be diagnosed at a later stage and more likely to die of their illness compared to the non-Hispanic/Latino whites.(17)

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Among women with breast cancer, Pacific Islanders are more likely to be diagnosed with advanced disease or larger tumors (>2 cm).(18)

●

Liver cancer incidence and death rates are more than twice as high in Pacific Islanders than in non-Hispanic/Latino whites.(19)

●

Pacific Islander women are less likely to survive five years after a cancer diagnosis than non-Hispanic/Latino white women.(19)

●

Despite the fact that the state of Hawaii has the lowest cancer mortality rate in the nation, Native Hawaiians experience cancer mortality second only to that of African American/black males and Native Alaskan females.(20)

●

Cancer is the leading cause of death for Pacific Islanders living in the United States.(21)

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A study in Guam revealed that Chamorros had significantly higher mortality rates than those of the U.S. average for patients diagnosed with cancer of the lungs, colon, breast, prostate, mouth, and nasopharynx.(22)

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The 5-year survival rate following diagnosis with all types of cancer is 47% for Native Hawaiians, compared to 57% for non-Hispanic/Latino whites and 55% for all races combined.(23)

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Of patients diagnosed with cancer, Pacific Islander men have a lower five-year survival rate than non-Hispanic/Latino whites.(24)

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Areca (betel) nut is the fourth most commonly used substance of abuse in the world after tobacco, alcohol and caffeine.(29) The adverse health effects associated with areca (betel) nut use include oral and oropharyngeal cancer.(30) In a study of cancer trends in Guam from 1971 to 1995, a continued high incidence of oral cancer particularly among Chamorro people was reported among habitual users of betel nut.(31)

Native Hawaiians/Pacific Islanders and Cancer

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A survey conducted in Saipan school district high schools reported that the majority of the students claimed regular use of Areca (betel) nut. When an oral examination was performed on these students, oral diseases such as oral leukoplakia and oral sub mucous fibrosis were detected.(32)

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Cancer is the second leading cause of death in American Samoa. In 2002, the leading cause of cancer death was cancers of the lung and respiratory tract (19%), followed by liver cancer (12%), prostate (11%), stomach (10%), colon(9%), and breast (8%).(33, 34)

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For the years 1997-2001, in the Republic of Palau, the most common cancer was cervical cancer (23%), followed by lung (17%), prostate (9%), liver (8%), and breast (6%).(35)

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Native Hawaiians are more likely to smoke (26%) compared to other ethnicities in Hawaii (14-17%) and more likely to be overweight (60%) compared to other ethnicities in Hawaii (41-48%).(36)

References 1.

US Census Bureau. We the People: Pacific Islanders in the United States. Census 2000 Special Reports. Department of Commerce Economics and Statistics Administration. Issued August 2005. Office of Minority Health. Native Hawaiians/Other Pacific Islanders Profile. Updated December 2007. Available at: http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID =71. Accessed February 2011. Shinagawa SM, Kagawa-Singer M, Chen M, Tsark J, Palafox N, Mackura, G. Cancer Registries and Data for “Asian Americans” and “Native Hawaiians and Pacific Islanders”: What Registrars Need to Know. Journal of Registry Management. 1999; 26(4):128-41. Haiman CA, Stram DO, Wilkens LR, et al. Ethnic and Racial Differences in the Smoking-Related Risk of Lung Cancer. N Engl J Med. 2006;354(4):333-42. Anderson I, Crengle S, Kamaka ML, Chen TH, Palafox N, Jackson-Pulver L. Indigenous Health in Australia, New Zealand, and the Pacific. Lancet. 2006;367(9524);1775-85.

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Braun KL, Fong M, Gotay C, Pagano IS, Chong C. Ethnicity and Breast Cancer in Hawaii: Increased Survival but Continued Disparity. Ethnicity and Disease. 2005; 15(3):453-60. Dach GB, Currie MJ, Mckenzie F, et al. Cancer Disparities in Indigenous Polynesian Populations: Maori, Native Hawaiians, and Pacific People. Lancet Oncol. 2008;9:473-84. Kroon E, Reddy R, Gunawardane K, et al. Cancer in the Republic of the Marshall Islands. Pac Health Dialog. 2004; 11(2);70-77. Kagawa-Singer M, Pourat N. Asian American and Pacific Islander Breast and Cervical Carcinoma Screening Rates and Healthy People 2000 Objectives. Cancer. 2000;89(3):696-705. Edwards QT, Li AX, Pike MC, et al. Ethnic Differences in the Use of Regular Mammography: The Multiethnic Cohort. Breast Cancer Res Treat. 2008;115(1):163-170. Ichiho HM, Gladu R, Keybond K, Ruben K. Cancer in Chuuk State, Federated States of Micronesia. Pac Health Dialog. 2004;11(2):30-36. Centers for Disease Control and Prevention. Behavioral Risk Factors Surveillance System. Available at: http://www.cdc.gov/brfss/. Accessed February 2011. Tsark JU, Braun KL, Pacific Islands Cancer Council, et al. Reducing cancer health disparities in the US-associated Pacific. J Public Health Manag Pract. 2007;13(1):49-58. Tanjasiri SP, LeHa’uli P, Finau S, Fehoko I, Skeen NA. Tongan-American Women’s Breast Cancer Knowledge, Attitudes, and Screening Behaviors. Ethn Dis. 2002;12(2):284-90. Hawaii Cancer Plan 2004-2009. Hawaii State Department of Health, Community Health Division. Available at: http://hawaii.gov/health/family-child-health/chronicdisease/cccp/plan.pdf. Accessed February 2011. McMullin JM, Taumoepeau L, Talakai M, Kivalu F, Hubbell FA. Tongan Perceptions of Cancer. Cancer Detect Prev. 2008; 32 supple1:S29-36. Biggs ML, Schwartz SM. Differences in Testis Cancer Survival by Race and Ethnicity: A Population-Based Study 1973-1999. Cancer Causes Control. 2004;15(5):437-44. Ghafoor A, Jemal A, Ward E, Cokkinides V, Smith R, Thun M. Trends in Breast Cancer by Race and Ethnicity. CA Cancer J Clin. 2003;53:342-55. Jemal A, Murray T, Ward E, et al. Cancer Statistics 2005. CA Cancer J Clin. 2005;55(1):10-30. National Cancer Institute CRCHD. ‘Imi Hale – Native Hawaiian Cancer Network. Available at: http://crchd.cancer.gov/cnp/pi-chong-abstract.html. Accessed February 2011. Native Hawaiian and Other Pacific Islander Populations. CDC Website. Updated May 2007. Available at: http://www.cdc.gov/omhd/populations/nhopi/nhopi.htm. Accessed February 2011.

22. Haddock RL, Talon RJ, Whippy HJ. Ethnic Disparities in Cancer Mortality among Residents Of Guam. Asian Pac J Cancer Prev. 2006;7(3):411-14. 23. Highlights in Minority Health and Health Disparities. CDC Website. http://www.cdc.gov/omhd/default.htm. Accessed February 2011. 24. Ward E, Jemal A, Cokkinides V, et al. Cancer Disparities by Race/Ethnicity and Socioeconomic Status. CA Cancer J Clin. 2004; 54: 78-93. 25. Cancer Health Disparities: A Fact Sheet. NCI website. Updated November 2005. Available at: http://www.cancer.gov/cancertopics/factsheet/disparities/ cancer-health-disparities. Accessed February 2011. 26. Mishra SI, Luce PH, Hubbell FA. Breast cancer screening among American Samoan women. Prev Med. 2001;33(1):9–17. 27. Mishra SI, Bastani R, Huang D, Luce PH, Baquet CR. Mammography Screening and Pacific Islanders: Role of Cultural and Psychosocial Factors. J Cancer Educ. 2007;22(1):32–36. 28. Mishra SI, Bastani R, Crespi CM, Chang LC, Luce PH, Baquet CR. Results of a Randomized Trial to Increase Mammogram Usage among Samoan Women. Cancer Epidemiol Biomarkers Prev. 2007;16(12):2594-2604. 29. Sullivan RJ, Hagen EH. Psychotropic Substance-Seeking: Evolutionary Pathology or Adaptation? Addiction. 2002;97(4):389-400. 30. Trivedy CR, Craig G, Warnakulasuriya S. The Oral Health Consequences of Chewing Areca Nut. Addiction Biology. 2002;7(1):115-25. 31. Haddock RL, Naval CL. Cancer in Guam: A Review of Death Certificates from 1971–1995. Pacific Health Dialog. 1997;4(1):66-75. 32. Oakley E, Demaine L, Warnakulasuriya S. Areca (Betel) Nut Chewing Habit among High-School Children in the Commonwealth of the Northern Mariana Islands (Micronesia). Bull World Health Organ. 2005;83(9):656-60. 33. Ruidas L, Adaoag A, Williams VT, Sesepasara ML. Cancer in American Samoa. Pac Health Dialog. 2004;11(2):17-22. 34. American Samoa Cancer Registry 2000-2002. Pago Pago: American Samoa: Department of Health; 2003. 35. Wong V, Taoka S, Kuartei S, Demei Y, Soaladaob F. Cancer in the Republic of Palau (Belau). Pac Health Dialog. 2004;11(2):64-69. 36. Park CB, Braun KI, Horiuchi BY, Tottori C, Onaka AT. Longevity Disparities in Multiethnic Hawaii: An Analysis of 2000 Life Tables. Public Health Reports. 2009; 124(1): 579584.