Reducing the Burden of Cancer Borne by African Americans: If Not Now, When?

270s Vol. 12, 270s–276s, March 2003 (Suppl.) Cancer Epidemiology, Biomarkers & Prevention

Sandra Millon Underwood1 341 for Asian/Pacific Islanders, and 245 for American Indians/ University of Wisconsin Milwaukee School of Nursing, Milwaukee, Wisconsin Alaska Natives (Table 1; Ref. 5). Corresponding cancer mor- 53211 tality rates were 267 (per annum) for African Americans, 205 for whites, 129 for Hispanics, 121 for Asian/Pacific Islanders, Introduction and 129 for American Indians/Alaska Natives (Table 2). Also, overall 5-year relative cancer survival rates were 53% among Cancer incidence, mortality, and survival rates differ among African Americans, as compared with 64% among whites and racial/ethnic populations in the United States. African Ameri- 62% in the total United States population (Table 3). cans have the highest overall cancer mortality rates and the Prostate cancer is the most common form of cancer among lowest survival rates. Published reports have highlighted chal- African-American men, followed by cancers of the lung and lenges faced by African Americans with regard to cancer pre- bronchus, cancers of the colon and rectum, non-Hodgkin’s vention, early detection, and disparities in treatment outcomes. lymphoma, and cancers of the oral cavity (Table 1; Refs. 3 and Past initiatives have been inadequate to substantially reduce the 5). When compared with other racial/ethnic groups in the burden of cancer borne by African Americans. To achieve this United States, African-American men have the highest age- national goal, efforts must be undertaken to garner the neces- adjusted incidence and mortality rates for at least nine forms of sary political will, resources, and support. cancer, including cancers of the lung and bronchus, colon and The United States Department of Commerce report enti- rectum, oral cavity and pharynx, stomach, urinary bladder, tled “Race and Ethnic Standards for Federal Statistics and pancreas, kidney, and renal pelvis and non-Hodgkin’s lym- Administrative Reporting” classifies citizens who trace their phoma. Among African-American women, the most common ancestry of origin to Sub-Saharan Africa as African American cancers are cancers of the lung and bronchus, colon and rectum, (1). According to the 2000 United States Census, African uterus, ovary, and pancreas (3, 5); African-American women Americans comprise the second largest racial group in the have the highest age-adjusted incidence and mortality rates for United States (2). Most are descendants of African men, cancers of the esophagus, larynx, oral cavity, and pancreas and women, and children who were forcibly transported from Sub- multiple myeloma. In addition, African Americans have the Saharan Africa to the United States and the Caribbean in the highest age-adjusted mortality rates for cancers of the breast, 17th to 19th centuries and sold into slavery. Others are their stomach, urinary bladder, uterine cervix, and uterine corpus and descendants who voluntarily came to the United States from the Hodgkin’s disease. When compared with whites, African Caribbean Islands, Sub-Saharan Africa, or other parts of the Americans of both sexes have poorer 5-year survival rates for world. There are approximately 35.5 million African Ameri- many cancers. cans, 93% of whom were born in the United States. Among those over age 16 years, approximately 43% have at least a high school education, 92% are employed, and 88% reside in met- Factors Influencing Cancer Morbidity and Mortality ropolitan areas. among African Americans Cancer is the second leading cause of death among African The American Cancer Society estimates that in 2003, approx- Americans. Data from the National Cancer Institute, American imately 132,700 African Americans will develop invasive can- Cancer Society, and Centers for Disease Control and Preven- cers, and approximately 63,100 will die from cancer (3). Cancer tion indicate that incidence and mortality rates for all cancers incidence rates are determined by several factors, including combined have decreased over the last decade (3–5). Advances biological, genetic, behavioral, and environmental influences, in early detection, screening, and treatment have reduced cancer whereas cancer mortality rates are also determined by factors, incidence and mortality, improved life expectancy, and en- such as site-specific cancer incidence, histology, co-morbid hanced quality of life for many cancer patients. However, when conditions (i.e., tobacco use, poor diet/nutrition, physical inac- cancer incidence and mortality rates of African Americans are tivity, and overweight/obesity), sociodemographic factors, and compared with other ethnic groups, African Americans are disparities in medical care. Decisions made by patients and significantly more likely to develop cancer and, subsequently, providers regarding cancer screening, treatment, and follow-up die from their disease. can also impact cancer morbidity and mortality among African In 1992–1999, overall age-adjusted cancer incidence rates Americans. for all cancers combined (per 1,000,000 in the population) were 527 for African Americans, 480 for whites, 330 for Hispanics, Tobacco Use Smoking of cigarettes, cigars, and pipes accounts for approximately 1 in 5 deaths in the United States and is the most Accepted 1/6/03. preventable cause of disease (4, 6–8). Tobacco use is the major 1 To whom requests for reprints should be addressed, at University of Wisconsin Milwaukee School of Nursing, 1021 East Hartford, Milwaukee, WI 53211. cause of 87% of lung cancers, emphysema, and chronic bron- Phone: (414) 229-6076; Fax: (414) 229-6474; E-mail: [email protected]. chitis combined. Additionally, smoking causes an estimated

Table 1 Age-adjusted Surveillance, Epidemiology, and End Results United States cancer incidence rate by race, United States, 1992–1999 (5)

All races White Black Asian/Pacific Islander American Indian Hispanic Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female All sites 475.8 570.5 413.6 480.4 568.2 424.4 526.6 703.6 404.8 348.6 408.9 306.5 244.6 277.7 224.2 329.6 393.1 290.5 Brain and nervous system 6.5 7.7 5.4 7.1 8.5 5.9 4.0 4.7 3.5 3.7 4.3 3.1 2.4 3.2 1.7 4.8 5.4 4.3 Female breast 132.1 137.0 120.7 93.4 59.4 82.6 Colon 39.4 45.3 35.0 39.1 46.3 34.5 47.8 52.9 44.3 32.5 37.9 28.3 25.3 28.5 22.8 24.5 28.8 21.3 Colon and rectum 54.3 64.6 46.7 53.9 64.4 46.1 61.9 70.7 55.8 47.9 58.7 39.5 35.2 40.7 30.8 35.7 43.9 29.7 Esophagus 4.5 7.5 2.1 4.2 7.1 1.9 8.0 12.9 4.4 3.0 5.6 1.0 2.8 4.9 a 2.9 5.5 1.0 Hodgkin’s lymphoma 2.7 3.0 2.4 3.0 3.3 2.7 2.4 2.7 2.1 1.0 1.2 0.9 aa a 2.3 2.8 1.9 Kidney and renal pelvis 10.7 14.8 7.4 10.9 15.1 7.6 12.3 17.1 8.7 6.2 9.0 4.0 11.3 15.6 8.1 9.6 13.0 7.0 Larynx 4.2 7.5 1.6 4.1 7.3 1.6 7.0 12.9 2.8 2.0 3.9 0.5 1.2 aa2.7 5.3 0.7 Leukemia 12.2 16.0 9.4 12.8 16.9 9.8 9.9 12.6 7.9 8.1 10.1 6.6 4.3 5.3 3.5 8.9 11.0 7.3 Liver and intrahepatic bile 5.3 8.1 3.1 4.2 6.4 2.5 6.2 9.6 3.5 13.8 21.1 7.8 6.8 8.1 5.8 7.7 11.6 4.6 duct Lung and bronchus 63.9 84.5 49.2 64.3 82.9 51.1 82.6 124.1 53.2 44.0 63.8 28.5 35.4 51.4 23.3 31.5 44.1 22.8 Melanoma 15.1 19.5 12.7 18.0 22.4 14.9 1.1 1.3 0.9 1.4 1.7 1.2 1.5 aa3.6 3.7 3.7 Multiple myeloma 5.5 6.9 4.6 5.2 6.5 4.2 11.4 13.1 10.3 3.4 4.4 2.7 3.1 3.6 2.7 4.8 5.8 4.0 Non-Hodgkin’s lymphoma 19.0 23.7 15.2 19.9 24.6 15.9 14.3 19.0 10.5 13.7 17.0 11.1 6.9 7.8 6.1 14.9 17.9 12.1 Oral cavity and pharynx 11.4 17.0 6.7 11.2 16.7 6.7 13.4 21.9 6.8 9.3 13.5 5.8 7.8 13.0 3.6 6.7 10.3 3.8 Ovary 17.1 18.1 12.2 12.6 10.2 13.5 Pancreas 11.0 12.5 9.8 10.7 12.2 9.5 16.2 17.6 15.0 9.4 11.3 8.0 7.0 8.0 6.3 9.0 9.7 8.4 Prostate 178.9 172.9 275.3 107.2 60.7 127.6 Stomach 9.3 13.5 6.3 7.9 11.7 5.2 13.9 19.6 9.9 18.5 24.9 13.6 10.4 13.9 7.7 12.8 17.6 9.3 Testis 5.0 5.9 1.2 2.1 2.6 3.4 Thyroid 6.3 3.5 9.0 6.4 3.6 9.3 3.6 1.9 5.0 7.9 3.9 11.5 3.9 a 5.6 5.7 2.5 8.8 Urinary bladder 20.2 35.5 9.2 21.9 38.9 9.8 12.4 19.6 7.5 9.8 16.7 4.4 3.9 6.6 a 9.6 16.7 4.5 Uterine cervix 10.5 9.6 13.3 11.7 7.7 17.5 Uterine corpus 24.5 26.0 17.7 17.0 10.6 15.6 a Statistic not shown. Rate based on Ͻ25 cases for the time interval.

Table 2 Age-adjusted Surveillance, Epidemiology, and End Results United States cancer mortality rate by race, United States, 1992–1999 (5)

All races White Black Asian/Pacific Islander American Indian Hispanic Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female All sites 208.7 264.7 172.7 205.1 258.1 171.2 267.3 369.0 204.5 128.6 160.6 104.4 128.6 154.5 110.4 129.2 163.7 105.7 Brain and nervous system 4.8 5.8 3.9 5.1 6.2 4.2 2.8 3.4 2.3 1.9 2.2 1.7 2.0 2.4 1.6 2.8 3.3 2.3 Female breast 29.7 29.3 37.3 13.1 14.8 17.5 Colon 14.9 19.3 11.6 14.8 19.1 11.6 14.2 17.8 11.5 15.4 20.8 11.1 9.9 12.2 8.0 11.2 15.1 8.4 Colon and rectum 22.3 27.1 18.9 21.9 26.7 18.4 29.1 34.8 25.4 13.7 16.5 11.6 12.8 14.6 11.3 13.2 16.6 10.6 Esophagus 4.3 7.5 1.8 4.0 7.0 1.6 7.9 13.8 3.7 2.3 4.0 1.0 2.5 4.3 1.0 2.3 4.2 0.8 Hodgkin’s lymphoma 0.6 0.7 0.4 0.6 0.7 0.5 0.5 0.7 0.4 0.2 0.3 0.1 0.2 aa0.6 0.8 0.4 Kidney and renal pelvis 4.3 6.2 2.9 4.3 6.2 2.9 4.2 6.2 2.8 1.9 2.8 1.2 4.7 6.4 3.3 3.5 5.0 2.3 Larynx 1.5 2.8 0.6 1.4 2.5 0.5 3.0 6.0 1.0 0.5 1.0 0.1 1.0 1.8 0.5 1.1 2.2 0.2 Leukemia 7.9 10.5 6.0 8.0 10.7 6.1 7.2 9.4 5.7 4.4 5.5 3.5 3.9 4.9 3.2 5.1 6.2 4.2 Liver and intrahepatic bile 4.4 6.3 2.9 4.0 5.7 2.7 5.9 9.0 3.8 10.9 16.2 6.6 5.0 6.7 3.8 6.5 9.2 4.3 duct Lung and bronchus 58.2 83.3 40.4 57.9 81.7 41.1 68.9 113.0 39.6 29.3 42.3 19.3 35.5 49.3 24.9 24.1 38.2 13.8 Melanoma 2.7 3.9 1.8 3.1 4.4 2.1 0.5 0.5 0.5 0.4 0.5 0.3 0.6 0.7 0.5 0.8 1.0 0.6 Multiple myeloma 3.9 4.9 3.3 3.6 4.5 3.0 7.7 9.3 6.7 1.9 2.4 1.6 2.8 3.3 2.4 2.9 3.4 2.5 Non-Hodgkin’s lymphoma 8.6 10.7 7.1 9.0 11.0 7.4 5.9 7.4 4.7 5.4 6.9 4.2 3.9 4.6 3.4 6.2 7.7 5.0 Oral cavity and pharynx 3.1 4.7 1.8 2.9 4.3 1.7 5.1 8.8 2.3 2.6 4.0 1.5 2.2 3.5 1.2 1.8 3.2 0.8 Ovary 9.1 9.4 7.7 4.8 4.9 5.8 Pancreas 10.6 12.3 9.3 10.3 12.0 9.0 14.7 16.7 13.2 7.5 8.8 6.6 5.8 5.8 5.6 7.7 8.8 6.9 Prostate 35.7 32.9 75.1 15.1 18.8 22.6 Stomach 5.2 7.5 3.6 4.6 6.6 3.2 10.1 14.7 7.0 10.3 13.4 7.9 5.2 6.9 3.9 7.0 9.5 5.2 Testis 0.3 0.3 0.1 0.1 a 0.3 Thyroid 0.5 0.4 0.5 0.4 0.4 0.5 0.4 0.3 0.5 0.7 0.5 0.9 0.3 aa0.6 0.4 0.7 Urinary bladder 4.4 7.7 2.4 4.5 8.0 2.3 4.1 5.9 3.1 1.8 2.8 1.1 1.4 2.1 0.9 2.2 3.8 1.1 Uterine cervix 3.2 2.8 6.7 3.1 3.3 3.8 Uterine corpus 4.2 3.9 7.0 2.2 2.3 3.0 a Statistic not shown. Rate based on Ͻ25 cases for the time interval.

430,000 deaths annually in the United States due to cancer and nonsmokers (9–13). Additionally, environmental tobacco other diseases of the heart, lung, and other organs. Environ- smoke increases the risk of asthma attacks, pulmonary infec- mental tobacco smoke can also contribute to deaths from cor- tions, middle ear infections, and other health problems, partic- onary heart disease, lung cancer, and other disease among ularly among children. Despite warnings regarding the health

Table 3 Surveillance, Epidemiology, and End Results survival rates, by race, sex, United States, 1992–1998 (5)

All races White Black Total Male Female Total Male Female Total Male Female All sites 62.4 61.9 63.0 63.8 63.5 64.2 52.6 54.0 51.0 Brain and nervous system 32.2 32.7 31.6 31.5 31.8 31.0 39.9 43.5 36.3 Female breast 86.2 87.6 72.5 Colon and rectum 61.9 61.9 61.9 62.6 62.6 62.7 52.8 52.7 52.8 Esophagus 13.3 13.4 13.1 14.7 14.7 14.8 8.3 9.0 6.7 Hodgkin’s disease 83.8 81.7 86.1 84.7 82.8 86.9 77.0 73.9 80.1 Kidney and renal pelvis 62.1 62.0 62.1 62.4 62.8 61.8 60.0 58.1 62.5 Larynx 64.4 65.9 58.9 65.9 67.7 59.2 54.1 54.3 54.0 Leukemia 45.9 47.1 44.3 47.3 48.4 45.7 38.4 37.9 39.0 Liver and intrahepatic bile duct 6.5 6.2 7.1 6.5 5.9 7.8 4.0 3.1 6.2 Lung and bronchus 14.7 13.1 16.7 15.0 13.3 17.0 12.3 10.8 14.7 Melanoma 89.1 87.0 91.5 89.3 87.1 91.8 65.5 69.4 61.9 Multiple myeloma 30.2 31.5 28.8 29.5 30.9 28.0 32.5 34.2 31.2 Non-Hodgkin’s lymphoma 55.0 51.4 59.5 56.1 52.7 60.2 46.1 41.4 53.8 Oral cavity and pharynx 56.4 54.6 60.1 58.8 57.8 60.9 34.9 29.5 49.3 Ovary 53.1 52.5 52.5 Pancreas 4.3 4.2 4.4 4.3 4.3 4.4 3.9 4.2 3.7 Prostate 97.0 97.8 92.6 Stomach 22.0 20.8 24.0 20.9 19.5 23.4 20.0 19.2 21.1 Testis 95.4 95.7 84.7 Thyroid 95.6 92.4 96.7 96.0 92.9 97.0 93.3 87.7 94.5 Urinary bladder 81.5 83.8 75.3 82.3 84.4 76.4 64.5 69.4 55.7 Uterine cervix 70.7 72.1 59.9 Uterine corpus 84.3 86.0 60.5

Table 4 Cigarette smoking by African Americans 18 years of age and older patterns of tobacco use persist, an estimated 1.6 million African by sex and age, 1994–2000 (19) Americans currently under the age of 18 years will become regular smokers, and 500,000 of these individuals will die of 1994 1995 1997 1998 1999 2000 smoking-related diseases. African-American males Age (yrs) 18–24 18.7a 14.6a 23.5 19.7 23.6 20.8 Diet and Nutrition 25–34 29.8 26.1 31.6 25.2 22.7 23.3 Diet can influence cancer risk. Diets high in fruits and vegeta- 35–44 44.5 36.3 33.9 36.1 34.8 30.8 bles, particularly green and dark yellow vegetables, cabbages, 45–64 41.2 33.9 39.4 37.3 35.7 32.2 and legumes, are associated with lower risk of cancers of the Ն 65 25.6 28.5 26.0 16.3 17.3 14.2 lung, colon, oral cavity, esophagus, stomach, and other sites African-American females Age (yrs) (26, 27). Diets high in fats, red meats (i.e., beef, pork, and 18–24 11.8 8.8a 11.5 8.1a 14.8 14.2 lamb), and whole milk and other dairy products have been 25–34 24.8 26.7 22.5 21.5 18.2 15.5 associated with increased risk of cancers of the colon, rectum, 35–44 28.2 31.9 30.1 30.0 28.8 30.2 prostate, and endometrium (28, 29). Cancer risks may be re- 45–64 23.5 27.5 28.4 25.4 22.3 25.6 duced by consuming healthful foods high in fiber (i.e., whole Ն65 13.6 12.3 10.7 11.5 13.5 10.2 grains, breads, and pastas) and low in red meats, whole-milk a These age-adjusted percentages should be considered unreliable because of dairy products, and other high-fat foods (30–32). small sample size. Dietary patterns of African Americans are influenced by diverse historical, regional, religious, social, economic, familial, and cultural factors; therefore, generalizations cannot ade- quately describe their dietary intake. African Americans and hazards of tobacco, an estimated 5.7 million African Americans whites with similar incomes and education typically consume smoke cigarettes or chew, dip, or sniff tobacco products (3, similar foods. Overall, African-American diets tend to be lower 14–18). Smoking prevalence of African Americans is reported in fruits, vegetables, and fiber and higher in saturated fats (33, to be higher among males and those ages 35–44 years (Table 4; 34). The United States Department of Agriculture Center for Refs. 3 and 19). An association has also been found between Health Policy and Protection estimates that only 5% of African tobacco use and discrimination toward African Americans (20– Americans consume healthy diets (34). However, the 2001 24). Tobacco companies target African Americans through Youth Risk Factor Survey found that most African-American advertising in magazines, billboards, sporting events, and other students consume the recommended five or more daily servings forms of entertainment (14, 15, 18, 21, 22). However, African- of fruit and vegetables, along with limited amounts of high-fat American college graduates of both sexes smoke less than their foods (35). counterparts with less education (Table 5). The American Leg- acy Foundation’s National Youth Tobacco Survey reports that 24% of African-American high school students and 14% of Alcohol Consumption African-American middle school students regularly use some Chronic alcohol consumption is associated with many seri- form of tobacco, primarily cigarettes and cigars (25). If these ous health-related conditions, including hypertension, cir-

Table 5 Cigarette smoking by African Americans 25 years of age and older by sex and education, 1994–2000 (19)

1994 1995 1997 1998 1999 2000 African-American males Education No high school diploma or GEDb 51.7 41.9 44.6 42.9 43.8 38.3 High school diploma or GED 37.8 36.6 39.0 32.8 32.5 29.1 Some college, no bachelor’s degree 29.2a 26.4 27.0 28.4 23.4 20.0 Bachelor’s degree or higher 26.8a 17.3a 14.5 15.3a 11.3 14.7 African-American females Education No high school diploma or GED 29.9 32.3 27.1 32.8 30.1 31.2 High school diploma or GED 22.6 27.8 29.1 24.3 22.4 25.4 Some college, no bachelor’s degree 28.3 20.8 24.3 21.7 22.3 20.4 Bachelor’s degree or higher 11.1a 17.3 12.5 9.0 13.4 10.8 a These age-adjusted percentages should be considered unreliable because of small sample size. b GED, General Education Development.

Table 6 Physical activity of African-American high school students, 2001 (70)

Participated in sufficient Participated in sufficient Participated in an No vigorous or vigorous physical moderate physical insufficient amount of moderate physical activitya (%) activityb (%) physical activityc (%) activityd (%) African American Male 72.4 23.7 25.4 8.4 Female 47.8 16.5 46.7 16.9 Total 59.7 20.1 36.4 12.9 a Activities that made students sweat and breathe hard for Ͼ20 min on Ͼ3 of the 7 days preceding the survey. b Activities that did not make students sweat or breathe hard for Ͼ30 min on Ͼ5 of the 7 days preceding the survey. c Had not participated in vigorous physical activity for Ͼ20 min on Ͼ3 of the 7 days preceding the survey and had not participated in moderate physical activity for Ͼ30 min on Ͼ5 of the 7 days preceding the survey. d Had not participated in either vigorous physical activity or Ͼ20 min or moderate physical activity for Ͼ30 min on any of the 7 days preceding the survey. rhosis, gastritis, colitis, depression, accidents, homicide, sui- colon and breast cancers, and adult-onset diabetes; (d) blood cide, and fetal alcohol syndrome in offspring of alcoholic pressure control; (e) improvement of strength, stamina, and mothers. Excess alcohol consumption is also associated with flexibility; (f) increased psychological well-being; and (g) cancers of the mouth, pharynx, larynx, esophagus, liver, and lower frequency of depression and anxiety. Unfortunately, breast (36–38) and, in combination with tobacco use, further many African-American high school students are not suffi- increases the risk of cancers of the mouth, larynx, and ciently active. Children should engage in at least 60 min or pharynx (39, 40). The National Institute on Alcohol Abuse more of moderate physical activity on most days per week (42). and Alcoholism and the United States Dietary Association However, less than half of African-American high school stu- recommend that daily alcohol consumption be limited to two dents engage in daily physical education classes. During an drinks for adult men and one drink for adult women. There average physical education class, male African-American high are individuals who should not drink any alcoholic bever- school students were more likely than their female counterparts ages: pregnant women or women trying to conceive; indi- (81% versus 71%, respectively) to exercise for at least 20 min viduals who plan to drive or engage in activities that require (Table 6). attention or skill; those taking certain medications; and recovering alcoholics (31, 32). However, 56% of African Overweight and Obesity Americans and 39% of African American women age 18 years or older are classified by the National Center for Being overweight or obese is associated with chronic diseases, Health Statistics as “consumers” of alcohol (19). including hypertension, dyslipidemia, respiratory disease, cardiovascular disease, non-insulin-dependent diabetes mellitus, glucose intolerance, gout, and osteoarthritis (45). Obesity is Physical Activity also associated with cancers of the breast (among postmeno- Increasing evidence suggests that physical activity may de- pausal women), colon, endometrium, esophagus, gallbladder, crease the risk for certain cancers, particularly cancers of the pancreas, and kidney (46–48). National data indicate that obe- colon, breast, pancreas, lung, endometrium, ovary, prostate, and sity (body mass index of 30.0 kg/m2 or greater) and being testicle (7, 41–44). Adults are recommended to engage in at overweight (body mass index of 25–29.99 kg/m2) have reached least 30 min of moderately intense physical activity on most epidemic proportions among African-American men and days per week (42). Despite the proven benefits of regular women (49). Recent data show that 57% of adult African- exercise, only 25% of adult African-American men and women American men and 66% of women are overweight (45), and engage in regular leisure-time physical activity (19). Benefits of similar trends have been reported among African-American regular exercise include: (a) maintenance of healthy body children. During the periods of 1963–1970 and 1994–1998, the weight, bones, muscles, and joints; (b) increased endurance and percentage of African-American children and adolescents who muscular strength; (c) decreased risk for cardiovascular disease, were overweight nearly tripled (19).

Table 7 Cancer screening practices of African Americans

Site Recommended Screening Guidelines (8) Cancer screening practices of African Americans (69)

Cancer-related check-up A cancer-related check-up is recommended every 3 years for Men and women Ն18 who visited a doctor for a 79.8% people aged 20–40 years and every year for people age 40 years routine checkup in the past year and older. This exam should include counseling and depending on a person’s age, might include examinations for cancers of the thyroid, oral cavity, skin, lymph nodes, testes, and ovaries, as well as examinations for some nonmalignant diseases. Breast (female) Women 40 years of age and older should have an annual Women Ն40 years of age who had a mammogram 73.4% mammogram, an annual clinical breast examination (CBE) by a within the last 2 years health care professional, and should perform monthly breast self-examination. The CBE should be conducted close to the scheduled mammogram. Women ages 20–39 years should have a CBE by a health care professional every 3 years and should perform monthly breast self-examinations. Colon and rectum Beginning at age 50 years, men and women should follow one of Men and women Ն50 years of age who had a fecal 55.7% the following examination schedules: occult blood test during the preceding year A fecal occult blood test every year and a flexible sigmoidoscopy every 5 yearsa A colonoscopy every 10 yearsa A double-contrast barium enema every 5 to 10 years Men and women Ն50 years of age who had a 44.2% sigmoidoscopy or proctoscopy during the preceding 5 years Prostate The American Cancer Society recommends that both the prostate- Blacks may begin PSA screening at a younger age specific antigen (PSA) blood test and the digital rectal (i.e., 45 years). examination be offered annually, beginning at age 50 years, to men who have a life expectancy of at least 10 years and to younger men who are at high risk. Men in high-risk groups, such as those with a strong familial predisposition (i.e., two or more affected first-degree relatives). Cervix All women who are or have been sexually active or who are 18 Women Ն18 years of age who had a Pap smear in 77.1% and older should have an annual Pap test and pelvic the last year examination. After three or more consecutive satisfactory examinations with normal findings, the Pap test may be performed less frequently. Discuss the matter with your physician. Endometrium Women at high-risk for cancer of the uterus should have a sample of endometrium tissue examined when menopause begins. a A digital rectal examination should be done at the same time as sigmoidoscopy, colonoscopy, or double-contrast barium enema. People who are at moderate or high risk for colorectal cancer should talk with a physician about a different testing schedule.

Cancer Screening Americans often lack accurate information regarding screening Cancer screening of asymptomatic persons can reduce can- examination procedures and the availability of early cancer cer morbidity and mortality. Screening for cancers of the oral detection programs (54, 62, 64–66). pharynx, breast, colon, rectum, cervix, prostate, and other sites can detect lesions that are curable, thereby improving survival (7). However, cancer screening tests are typically Access, Utilization, and Delivery of Cancer Care under-used by African Americans for diverse reasons, in- Despite efforts to improve availability of health care in the cluding lack of accurate information about cancer screening United States, many African Americans do not have access to examinations, fear of pain and embarrassment, a lack of quality cancer care, particularly the elderly, medically under- understanding that cancer screening procedures are recom- served, poor, or uninsured. Additionally, disparities often re- mended in the absence of problems or symptoms, and cost of main even after adjustments have been made for socioeconomic screening and concurrent loss of wages due to absence from differences. For example, elderly African Americans are less work (50–54). Even when screening occurs, follow-up of frequently offered cancer screening and early detection services abnormal test results may be delayed, resulting in African Americans more frequently being diagnosed with metastatic (Table 7; Refs. 67 and 68). Among the 12% of African Amer- disease (5, 55–57). icans who reside in rural communities, cancer screening pro- Access to cancer screening and early detection must be grams are even more limited, and an additional 53% reside in made available to at-risk individuals. Unfortunately, many Af- densely populated urban communities that typically have a rican Americans do not consider cancer screening a priority shortage of health care services. In addition, approximately because other personal, family, financial and social issues typ- one-fourth of African Americans live in poverty, 19% have no ically take precedence (53, 54, 58–62). Also, cancer often usual source of health care, and 17% do not have the financial evokes images of pain, mutilation, suffering, and death for means to seek good health care, including cancer screening. many African Americans (50, 63), resulting in feelings of fear, These individuals also have limited access to optimal curative hopelessness, pessimism, and fatalism. Additionally, African and palliative care when cancers develop (19, 69).

Opportunities and Challenges 16. Cigarette smoking among adults–United States, 1994. Morb. Mortal. Wkly. African Americans are approximately 30% more likely to die of Rep., 45: 588–590, 1996. 17. United States Department of Health and Human Services. Tobacco Use cancer than whites and are twice as likely to die from cancer among U. S. Racial/Ethnic Groups—African Americans, American Indian and than Asian or Pacific Islanders, American Indians, and Hispan- Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report ics. The burden of cancer borne by African Americans far of the Surgeon General. Rockville, MD: Office on Smoking and Health, United exceeds that of other racial groups due to lifestyle, behavioral, States Department of Health and Human Services, 1998. and socioeconomic influences and inadequate access to medical 18. Stoddard, J. L., Johnson, C. A., Sussman, S., Dent, C., and Boley-Cruz, T. Tailoring outdoor tobacco advertising to minorities in Los Angeles County. care. If current knowledge, medical expertise, and resources J. Health Commun., 3: 137–146, 1998. were more readily available to African Americans, their cancer 19. Centers for Disease Control. National Center for Health Statistics. www. morbidity and mortality rates would almost certainly decline. cdc.gov/nchs. Unfortunately, few such initiatives have actually been designed 20. Robinson, R., Orleans, C., James, D., and Sutton, C. Pathways to Freedom: and launched. Issues and challenges regarding their cancer Winning the Fight Against Tobacco (guide). Philadelphia: Fox Chase Cancer prevention and surveillance practices have been well docu- Center, 1992. mented, and the time has come to eliminate the excess cancer 21. Cummings, K. M., Giovino, G., and Mendicino, A. J. Cigarette advertising burden faced by African Americans. Reducing this cancer bur- and black-white differences in brand preference. Public Health Rep., 102: 698– den borne by African Americans and other underserved Amer- 701, 1987. 22. Stoddard, J. L., Johnson, C. A., Boley-Cruz, T., and Sussman, S. Targeted icans has often been touted as a national goal. However, there tobacco markets: outdoor advertising in Los Angeles minority neighborhoods. must be political will, public support, and financial resources to Am. J. Public Health, 87: 1232–1233, 1997. accomplish this goal. The question remains—if not now, then 23. Carpenter, C. L., Jarvik, M. E., Morgenstern, H., McCarthy, W. J., and when? London, S. J. Mentholated cigarette smoking and lung-cancer risk. Ann. Epide- miol., 9: 114–120, 1999. 24. Cooley, M. E., and Jennings-Dozier, K. Lung cancer in African Americans. References A call for action. Cancer Pract., 6: 99–106, 1998. 1. United States Department of Commerce. Directive No. 15. Race and Ethnic 25. Tobacco use among middle and high school students–Florida, 1998 and 1999. Standards for Federal Statistics and Administrative Reporting, Statistical Policy Morb. Mortal. Wkly. Rep., 48: 248–253, 1999. Handbook, pp. 37–38. Washington, DC: United States Department of Commerce, 26. Block, G., Patterson, B., and Subar, A. Fruit, vegetables, and cancer preven- Office of Federal Statistical Policy and Standards, 1978. tion: a review of the epidemiological evidence. Nutr. Cancer, 18: 1–29, 1992. 2. Population Estimates Program. Washington, DC: United States Census Bu- 27. Steinmetz, K. A., and Potter, J. D. Vegetables, fruit, and cancer. I. Epide- reau, Population Division, 2001. miology. Cancer Causes Control, 2: 325–357, 1991. 3. Ghafoor, A., Jemal, A., Cokkinides, V., Cardinez, C., Murray, T., Samuels, A., 28. Committee on Diet and Health. Diet and Health: Implications for Reducing and Thun, M. J. Cancer statistics for African Americans. CA Cancer J. Clin., 52: Chronic Disease Risk. Washington, DC: Food and Nutrition Board, Commission 326–341, 2002. on Life Sciences, National Research Council, 1989. 4. United States Department of Health and Human Services. Healthy People 29. Hursting, S. D., Thornquist, M., and Henderson, M. M. Types of dietary fat 2010: Understanding and Improving Health, 2nd ed. Washington, DC: United and the incidence of cancer at five sites. Prev. Med., 19: 242–253, 1990. States Government Printing Office, 2000. 30. Byers, T., Nestle, M., McTiernan, A., Doyle, C., Currie-Williams, A., Gan- 5. Ries, L., Eisner, M., Kosary, C., Hankey, B., Miller, B., Clegg, L., and sler, T., and Thun, M. American Cancer Society guidelines on nutrition and Edwards, B. SEER Cancer Statistics Review, 1973–1999 (http://seer. cancer. physical activity for cancer prevention: reducing the risk of cancer with healthy gov/csr/1973_1999/). Bethesda, MD: National Cancer Institute, 2002. food choices and physical activity. CA Cancer J. Clin., 52: 92–119, 2002. 6. Centers for Disease Control. Cigarette smoking-attributable mortality and 31. United States Department of Agriculture and United States Department of years of potential life lost-United States, 1984. Morb. Mortal. Wkly. Rep., 46: Health and Human Services. Nutrition and Your Health: Dietary Guidelines for 444–450, 1997. Americans, 4th ed. USDA Home and Garden Bulletin, 232, 1995. 7. American Cancer Society. Cancer Prevention and Early Detection. Atlanta, 32. Committee by the Agricultural Research Service. Report of the Dietary GA: American Cancer Society, 2001. Guidelines Advisory Committee on the Dietary Guidelines for Americans. Wash- 8. American Cancer Society. Cancer Facts and Figures, 2002. Atlanta, GA: ington, DC: United States Department of Agriculture, 2000. American Cancer Society, 2002. 33. Dixon, B. Good Health for African Americans. New York: Crown, 1994. 9. Centers for Disease Control and Prevention. Strategies for reducing exposure 34. Basiotis, P., Lino, M., and Anand, R. Report card on the diet quality of to environmental tobacco smoke, increasing tobacco-use cessation, and reducing African Americans. Family Economics and Nutrition Review, 11: 61–63, 1998. initiation in communities and health care systems: a report on recommendations 35. Centers for Disease Control and Prevention. Youth Risk Factor Surveillance of the Task Force on Community Prevention Services. Morb. Mortal. Wkly. Rep., System. www.cdc.gov/yrbss, 2001. 49: 1–12, 2000. 36. McCoy, G. D., and Wynder, E. L. Etiological and preventive implications in 10. United States Department of Health and Human Services. The Health Con- alcohol carcinogenesis. Cancer Res., 39: 2844–2850, 1979. sequences of Involuntary Smoking: A Report of the Surgeon General. Rockville, MD: Office on Smoking and Health, United States Department of Health and 37. Blot, W. J. Alcohol and cancer. Cancer Res., 52: 2119sϪ2123s, 1992. Human Services, 1986. 38. Higginson, J., Muir, C., and Munoz, N. Human Cancer: Epidemiology and 11. United States Environmental Protection Agency. Respiratory Health Effects Environmental Causes. New York: Cambridge Univesity Press, 1992. of Passive Smoking: Lung Cancer and Other Disorders. Washington, DC: Office 39. Blot, W. J., McLaughlin, J. K., Winn, D. M., Austin, D. F., Greenberg, R. S., of Research and Development, Office of Air and Radiation, United States Envi- Preston-Martin, S., Bernstein, L., Schoenberg, J. B., Stemhagen, A., and Frau- ronmental Protection Agency, 1992. meni, J. F., Jr. Smoking and drinking in relation to oral and pharyngeal cancer. 12. Committee on Passive Smoking. Environmental Tobacco Smoke: Measuring Cancer Res., 48: 3282–3287, 1988. Exposures and Assessing Health Effects. Washington, DC: Board on Environ- 40. Elwood, J. M., Pearson, J. C., Skippen, D. H., and Jackson, S. M. Alcohol, mental Studies and Toxicology, National Research Council, National Academy smoking, social and occupational factors in the aetiology of cancer of the oral Press, 1986. cavity, pharynx and larynx. Int. J. Cancer, 34: 603–612, 1984. 13. Glantz, S. A., and Parmley, W. W. Passive smoking and heart disease. 41. Friedenreich, C. M. Physical activity and cancer prevention: from observa- Epidemiology, physiology, and biochemistry. Circulation, 83: 1–12, 1991. tional to intervention research. Cancer Epidemiol. Biomark. Prev., 10: 287–301, 14. Hackbarth, D. P., Schnopp-Wyatt, D., Katz, D., Williams, J., Silvestri, B., 2001. and Pfleger, M. Collaborative research and action to control the geographic 42. United States Department of Health and Human Services. Physical Activity placement of outdoor advertising of alcohol and tobacco products in Chicago. and Health: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Public Health Rep., 116: 558–567, 2001. Control and Prevention, United States Department of Health and Human Services, 15. Hackbarth, D. P., Silvestri, B., and Cosper, W. Tobacco and alcohol bill- 1996. boards in 50 Chicago neighborhoods: market segmentation to sell dangerous 43. Martinez, M. E., Giovannucci, E., Spiegelman, D., Hunter, D. J., Willett, products to the poor. J. Public Health Policy, 16: 213–230, 1995. W. C., and Colditz, G. A. Leisure-time physical activity, body size, and colon

cancer in women. Nurses’ Health Study Research Group. J. Natl. Cancer Inst. 57. Jones, B. A., Kasl, S. V., Curnen, M. G., Owens, P. H., and Dubrow, R. Can (Bethesda), 89: 948–955, 1997. mammography screening explain the race difference in stage at diagnosis of 44. Thune, I., Brenn, T., Lund, E., and Gaard, M. Physical activity and the risk breast cancer? Cancer (Phila.), 75: 2103–2113, 1995. of breast cancer. N. Engl. J. Med., 336: 1269–1275, 1997. 58. Collins, M. Increasing prostate cancer awareness in African American men. 45. National Heart, Lung and Blood Institute Clinical Guidelines on the Identi- Oncol. Nurs. Forum, 24: 91–95, 1997. fication, Evaluation and Treatment of Overweight and Obesity in Adults: The 59. Lawson, E. J. A narrative analysis: a black woman’s perceptions of breast Evidence Report. NIH Publication No. 98-4083. Bethesda, MD: NIH, 1998. cancer risks and early breast cancer detection. Cancer Nurs., 21: 421–429, 1998. 46. Harvard Report on Cancer Prevention. Causes of human cancer. Obesity. 60. Hoffman-Goetz, L., Breen, N. L., and Meissner, H. The impact of social class Cancer Causes Control, 7 (Suppl. 1): S11ϪS13, 1996. on the use of cancer screening within three racial/ethnic groups in the United 47. Michaud, D. S., Giovannucci, E., Willett, W. C., Colditz, G. A., Stampfer, States. Ethn. Dis., 8: 43–51, 1998. M. J., and Fuchs, C. S. Physical activity, obesity, height, and the risk of pancreatic 61. Powe, B. D. Fatalism among elderly African Americans. Effects on colorectal cancer. JAMA, 286: 921–929, 2001. cancer screening. Cancer Nurs., 18: 385–392, 1995. 48. Devesa, S. S., Blot, W. J., and Fraumeni, J. F., Jr. Changing patterns in the 62. Underwood, S. M. Reducing the cancer burden among African Americans: a incidence of esophageal and gastric carcinoma in the United States. Cancer call to arms. Cancer (Phila.), 83: 1877–1884, 1998. (Phila.), 83: 2049–2053, 1998. 63. Powe, B. D., and Weinrich, S. An intervention to decrease cancer fatalism 49. Mokdad, A. H., Bowman, B. A., Ford, E. S., Vinicor, F., Marks, J. S., and among rural elders. Oncol. Nurs. Forum, 26: 583–588, 1999. Koplan, J. P. The continuing epidemics of obesity and diabetes in the United 64. McMahon, L. F., Jr., Wolfe, R. A., Huang, S., Tedeschi, P., Manning, W., Jr., States. JAMA, 286: 1195–1200, 2001. and Edlund, M. J. Racial and gender variation in use of diagnostic colonic 50. Phillips, J. M. Breast cancer and African American women: moving beyond procedures in the Michigan Medicare population. Med. Care (Phila.), 37: 712– fear, fatalism, and silence. Oncol. Nurs. Forum, 26: 1001–1007, 1999. 717, 1999. 51. Anthony, A. How African American women look at breast cancer: percep- 65. Amey, C. H., Miller, M. K., and Albrecht, S. L. The role of race and residence tions from rural North Carolina. North Carolina Med. J., 60: 284–287, 1999. in determining stage at diagnosis of breast cancer. J. Rural Health, 13: 99–108, 52. Jennings, K. M. Getting a Pap smear: focus group responses of African 1997. American and Latina women. Oncol. Nurs. Forum, 24: 827–835, 1997. 66. Feldman, R. H., and Fulwood, R. The three leading causes of death in African 53. Plowden, O. Using the health belief model in understanding prostate cancer Americans: barriers to reducing excess disparity and to improving health behav- in African American males. J. Assoc. Black Nursing Faculty, 10: 4–8, 1999. iors. J. Health Care Poor Underserved, 10: 45–71, 1999. 54. Underwood, S. M. Breast cancer screening among African American women: 67. Gorey, K. M., and Vena, J. E. The association of near poverty status with addressing the needs of African American women with known and no known risk cancer incidence among black and white adults. J. Community Health, 20: factors. J. Natl. Black Nurses Assoc., 10: 46–55, 1999. 359–366, 1995. 55. Burns, R. B., McCarthy, E. P., Freund, K. M., Marwill, S. L., Shwartz, M., 68. Geiger, H. J. Race and health care–an American dilemma? N. Engl. J. Med., Ash, A., and Moskowitz, M. A. Black women receive less mammography even 335: 815–816, 1996. with similar use of primary care. Ann. Intern. Med., 125: 173–182, 1996. 69. Centers for Disease Control. Behavioral Risk Factor Surveillance System. 56. Chen, F., Trapido, E. J., and Davis, K. Differences in stage at presentation of www.cdc.gov/brfss. breast and gynecologic cancers among whites, blacks, and Hispanics. Cancer 70. Centers for Disease Control and Prevention. Youth Risk Behavior Survey. (Phila.), 73: 2838–2842, 1994. Atlanta, GA: Centers for Disease Control and Prevention, 2001.

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