WELCOME

Introduction

Asthma

Cancer
Breast Cancer
Cervical Cancer
Pap Test
Mammogram

Diabetes

Heart disease
and Stroke

Obesity

Nutrition

Physical
Activity

Tobacco
Use

Appendixes

Cancer

Cancer is the second leading cause of death in the United States.  Cancer death rates vary by gender, race, and ethnicity.

Female cancer death rates peaked in 1991 at 142.2 per 100,000.  Overall, female deaths decreased an average of 0.4 per year through 1996, with a significant decrease in breast cancer rates but a continued increase in lung cancer death rates.  From 1990 to 2000, the overall cancer death rate declined less for women than for men.

Notable disparities in death rates exist.  For example, in 2000, the cervical cancer death rate was 5.7 per 100,000 for non-Hispanic black women compared to 2.4 per 100,000
for non-Hispanic white women.

Breast Cancer

One out of eight women will develop breast cancer over the course of her lifetime. Breast cancer is the second leading cause of cancer death among all women in the United States, second to lung cancer.⁵ The breast cancer risk for women of color varies dramatically within population groups as shown in the chart, Breast Cancer Deaths for Women.

Lack of health insurance is a strong predictor of death.  Women with no insurance have a 2.3 times higher risk of death from breast cancer than women with private insurance.⁵ Being divorced, separated, or never married also increases risk of death.  Variables that have no significant effect on risk of breast cancer death include years of education, occupation, smoking, coexisting illness, and source of health care, although a number of coexisting illnesses predict risk of death from all causes combined. 

African American women have a higher death rate from the disease than all population groups (36.4 per 100,000 women as shown in the chart Breast Cancer Deaths for Women), due most likely to later diagnosis and to later entrance into treatment, resulting in more advanced disease. 

As shown in the map Breast Cancer Deaths for Black, Non-Hispanic Women, the breast cancer death rate varies substantially by State, with the highest rate, 45.8 per 100,000 African American women, occurring in the Nebraska. The lowest rate is 26.6 per 100,000 in Massachusetts.

Other groups of women of color have much lower death rates. The rate of breast cancer deaths is 14.3 per 100,000 for American Indian/Alaska Native women, 12.9 for Asian/Pacific Islander women, and 16.6 for Hispanic women. African Americans with breast cancer face more than twice the risk of dying compared with white Americans, primarily because they are diagnosed at more advanced stages of disease. In a detailed analysis of the difference in breast cancer survival between African Americans and whites, researchers found that African Americans had a 2.1 times greater risk of dying from breast cancer during the study
period and a 2.2 times greater risk of dying from any cause.⁵ The late diagnosis of breast cancer within the African American community may be associated with socioeconomic and cultural factors, including limited access to medical care.

Analysis of medical data (tumor stage and pathology, comorbidity, and treatment) and sociodemographic data (age, marital status, economic status, occupation, and health care) indicates the role of these variables, alone or in combination, in the observed discrepancies in cancer deaths.

Approximately 40 percent of the differences in survival are explained by more advanced disease stage at diagnosis among African Americans. African American women score significantly worse than white women on measures of disease stage, including tumor size, number of cancerous lymph nodes, and estrogen receptor status. 

Another 15 percent of the African American/ white survival differences is explained by histologic differences (appearance of tumor cells under microscopic analysis).  While stage differences are likely the result of

African  American women’s lower use of early detection methods, including mammography and clinical breast exams, many investigators suspect that differences in histologic features such as tumor grade may reflect underlying racial differences in the biology of the disease.

The Black/White Cancer Survival Study of the National Cancer Institute (NCI) supports the conclusion that both types of factors are involved.⁶  Even when stage of disease and histologic features are taken into account, African American women have a significantly greater risk of death, which is not explained by differences in treatment. Part of this residual difference is attributable to body mass index, a measure of weight versus height. African American women are more likely than white women to be categorized as overweight based on body mass index, and women with high body mass index are more likely to die from breast cancer or from any cause.

African American women’s survival from breast cancer has made substantial gains in recent decades, from a 5-year survival rate of 46 percent of women diagnosed in 1960-1963 to 62 percent of women diagnosed in 1983-1988 (the period corresponding to the NCI study). African American women’s rates have continued to lag behind those of whites; their 5-year survival rate was 72.5 percent for cases diagnosed in 1992–1998, compared to 87.6 percent for white women.⁷

Hispanic women have lower incidence rates of breast cancer than African American women, but they have a poorer survival rate, due in part to the advanced stages of the disease at time of diagnosis. However, breast cancer in Hispanic women is increasing faster than in other women. Although Hispanic American women have the highest mammography rates, these rates still fall short of the U.S. Department of Health and Human Services’ Healthy People 2010 goal of screening for 60 percent of all women aged 50 years and older.⁶

Culturally sensitive and Spanish language health education materials would increase knowledge of risk factors among Hispanic women and would encourage them to get more regular mammograms and clinical checkups.

American Indian and Alaska Native women have the second lowest overall breast cancer mortality rate, compared with African American and Hispanic women. 

Significant variation in incidence rates of breast cancer occurs among different tribes, with the highest incidence rate, 21 per 100,000, in the Indian Health Service (IHS) Bemidji service area tribe.  Fifty-four percent of American Indian and Alaska Native women aged 50 years and older had not had a mammogram in the past 24 months. Regular screenings can be difficult for American Indian and Alaska Native women who live far from health clinics or who are too poor to have routine access to health care.⁸ 

The breast cancer death rate for Asian American and Pacific Islander women is 12.9 per 100,000, lower than the mortality rates for women of other racial/ethnic groups as shown in the chart.  However, the incidence rate of breast cancer varies by subpopulation, with the highest incidence rate being reported in Japanese American women and Filipina women.  Asian American women often do not have regular breast cancer screening and usually are diagnosed at a later stage of the cancer.  Fifty-four percent of Asian American women aged 40 years and over have not had a mammogram in the past 2 years.⁹

Despite the rise in breast cancer incidence, death rates from breast cancer have declined since 1990.  The decline in breast cancer mortality has been attributed to improvements in breast cancer detection and treatment, including the use of chemotherapy and mammography screening. However, breast cancer incidence rates vary within each race and ethnic group.⁹

Cervical Cancer

Cervical cancer is the 10th most common cancer among females in the United States, with an estimated 12,800 new cases in 2000.  The number of new cases of cervical cancer is higher among racial and ethnic minority females than among white females.  An estimated 4,600 U.S. females were expected to die from cervical cancer in 2000.¹⁰ Cervical cancer accounts for about 1.7 percent of cancer deaths among females.  Infections of the cervix with certain types of sexually transmitted human papilloma virus increase risk of cervical cancer and may be responsible for most cervical cancer in the United States.¹¹

Compared to breast cancer death rates, cervical cancer rates are considerably lower. The death rates were 27.0 per 100,000 females in 1998 and 2.9 per 100,000 females in 1999, respectively.

Considerable evidence suggests that screening can reduce the number of deaths from cervical cancer.  Invasive cervical cancer is preceded in a large proportion of cases by precancerous changes in cervical tissue that can be identified with a Pap test.  If cervical cancer is detected early, the likelihood of survival is almost 100 percent with appropriate treatment and followup; that is, almost all cervical cancer deaths could be avoided if all females complied with screening and followup recommendations.¹²  

Risk factors for cervical cancer are:

	First intercourse at an early age
	Multiple sex partners
	Genital infection with human papilloma virus
	Smoking

 Prevention and early detection require:

Papanicolaou test (Pap smear)

As the chart Cancer of the Uterine Cervix Deaths for Women shows, African American women had the highest death rate from cervical cancer (5.9 per 100,000). Death rates for all other groups of women (including Hispanic, American Indian/Alaska Native, and Asian/Pacific Islander) were 3.4 per 100,000 women or less.¹³  The 5-year relative survival rate of cervical cancer for African American women  from 1988 to 1997 was 68 percent, compared to that of 78 percent for white women.¹³

One study has shown that 31 percent of highly acculturated Hispanic women in the U.S. culture have reported having multiple partners within a 6-month period, thus increasing their exposure to a cervical cancer risk factor.  The tendency of the Hispanic woman to delay seeking treatment until advanced stages of a disease increases the incidence and rate of cervical cancer.  Cervical cancer incidence for Hispanic women in Los Angeles County, Denver, New York City, New Jersey, and Dade County (Florida) ranged from a low of 10 per 100,000 (Dade County) to a high of 39 per 100,000 (New Jersey). The incidence in Dade County reflects Cuban women primarily, while the New Jersey rate mainly reflects Puerto Rican women. Rates in the other three places were around 20 per 100,000 women.¹³

Cervical cancer and breast cancer rates for Asian American and Pacific Islander women are approaching those for whites.  For reasons not fully understood, Vietnamese women residing in the
United States have more than two and a half times the cervical cancer rate of any other racial or ethnic group in the United States (43 per 100,000).  Korean American women also have a high rate (15 per 100,000). Subpopulations with low incidences of cervical cancer include Chinese American (7 per 100,000), Native Hawaiian (9 per 100,000), and Filipina (10 per 100,000).  Women from Southeast Asia tend to have more severe cases of cervical cancer due to late diagnosis and are less likely to follow up with treatment.  This finding is due in part to cultural barriers that exist between health care professionals and Asian immigrant women.¹³

U.S. mortality rates are about 50 to 80 percent lower than the incidence rates for cervical cancer. The ethnic patterns in mortality differ somewhat from those seen in incidence. Black women have the highest age-adjusted mortality rate from cervical cancer and are followed by Hispanic women. The lowest mortality from this disease occurs among Japanese women, whose rates are less than one-fourth the rates among black women. Mortality rates are not available for comparison, however, for Vietnamese, Korean, Alaska Native, or American Indian (New Mexico) women.¹⁴

The age-adjusted cervical cancer death rate for females in the IHS area population was 3.6 per 100,000 in 1990–1997.  A significant variation in incidence rates exists among different tribes, the highest being among the women living in the IHS Aberdeen service area.  The death rate among American Indian and Alaska Native women is high, partly due to late diagnosis.¹³

Although American Indian women in New Mexico had a low incidence of cervical cancer, their death rate was the highest reported among the groups of women in the National Cancer Registry—8 per 100,000 (1988–1992). When
age-adjusted mortality for American Indian/ Alaska Native women in the IHS service areas was examined for 1991–1993, however, the highest reported death rate was for the Aberdeen service area (North Dakota, South Dakota, Nebraska, and Iowa)—more than 14 deaths per 100,000 American Indian women. In Alaska and in the Navajo service area (four corners of the States of Utah, Colorado, New Mexico, and Arizona), 6 deaths per 100,000 women were reported. The death rate among American Indian women living in the Albuquerque IHS service area (parts of New Mexico, Colorado, and Texas) was lower than the rate reported from the National Cancer Registry for American Indian women in New Mexico (8 per 100,000).¹³

Pap Tests

The Papanicolaou test or Pap test is the most effective method for the detection of cervical cancer. Mortality rates reported for cervical cancer are relatively low for all racial and ethnic populations.⁹  The low mortality rates are attributed to early detection and treatment of the disease. Nearly all deaths from cervical cancer can be prevented.  However, large percentages of minority women reported that they have not had a Pap test within the past 3 years as shown in the chart Pap Smear Status for Women.¹⁵

Five percent of each of these groups of women—black non-Hispanic and American Indian/Alaska Native—reported (during the 1991–1993 period) having had an abnormal Pap smear. Four percent of Hispanics and 2 percent of Asians also reported an abnormal Pap smear.⁵

American women of all races and ethnicity should have a Pap smear at least once every 3 years.  Some women need Pap smears more often.⁵

	The absence of symptoms may lead to the belief that there is no need for screening
	Lack of physician referrals (particularly for older women)
	Cost and/or lack of health insurance
	Language barriers