This paper was presented at the President's Cancer Panel
Conference on Avoidable Causes of Cancer held 7-8 April 1994 in Bethesda,
Maryland. Manuscript received 9 March 1995; manuscript accepted 24 March
1995.
Address correspondence to Dr. Bailus Walker, Jr. University
Cancer Center, Howard University, 2041 Georgia Avenue NW, Washington, DC
20060. Telephone: (202) 806-9259. Fax: (202) 806-4898.
Abbreviation used: SEER, Surveillance, Epidemiology, and
End Results Program.
Introduction
Interest has intensified in recent years regarding the variation
of cancer incidence and mortality among racial groups, particularly among
African Americans, who comprise the largest racial minority group in the
United States (1). Particularly germane are demographic changes,
the lack of substantial gains against established cancers, and increasing
evidence that higher percentages of African Americans and Hispanics than
whites live in areas polluted by potential environmental carcinogens (2).
Descriptive and analytic epidemiologic studies have provided abundant information
concerning the African American community's disproportionate cancer burden,
a burden that is marked by increasing mortality rates for many cancers in
sharp contrast to more favorable trends among whites (3).
During the period from 1987 to 1991, African Americans in the United
States experienced higher incidence and mortality rates than whites for
multiple myeloma and for cancers of the oropharynx, colorectum, lung and
bronchus, cervix, and prostate, (Table 1). African Americans had lower incidence
and mortality for cancer of the urinary bladder. The incidence of breast
cancer was higher among white women, but mortality was higher among African
American women. Five-year relative survival for the period 1983 to 1990
generally was lower among African Americans than whites for cancers of the
oropharynx, colorectum, cervix, prostate, and female breast, but slightly
higher for multiple myeloma. From 1973 to 1991, there were significant
declines in cervical cancer incidence among women of both races, oropharyngeal
cancer mortality among whites, and bladder cancer mortality among both whites
and African Americans.
This report highlights selected cancer sites and briefly considers
some of the potential risk factors investigated to explain differences in
incidence and mortality among African Americans and whites. More detailed
discussions of risk factors such as socioeconomic status (4-11) can
be found elsewhere.
Oral Cavity and Pharynx
The National Cancer Institute estimated that there would be 29,600 new
cases and 7925 deaths in 1994 attributable to cancer of the oral cavity
and pharynx, including lip, salivary gland, and nasopharynx (Table 1) (3).
African American men have the highest incidence and mortality rates, and
the racial disparity has been increasing over time. African American men
are the only racial/gender group to experience increases in both incidence
and mortality during the 1987 to 1991 period (3). In addition, African
American men have the poorest 5-year survival rates for these types of cancer.
The primary risk factors for cancer of the oral cavity and pharynx are
alcohol and tobacco consumption (12). Day et al. (12) reported
that differences in the relative risks and prevalences of exposure to alcohol
and tobacco account for most of the racial variation. The interactions (multiplicative
effects) of alcohol and tobacco were associated with greater risk among
African
Americans than whites. The reasons for higher risks among African Americans
who consume alcohol than among white individuals who drink are not known,
but may be related to the types of alcohol beverages consumed. Other factors,
such as diet, may also play a role. Interventions aimed at reducing alcohol
and tobacco use represent the best opportunities to prevent these cancers.
Tobacco use trends suggest that interventions should target certain age
groups (Table 2).
Colorectal
Colorectal cancer is one of the nation's most common malignancies, accounting
for one in every eight cancers in the United States. In 1994, there were
an estimated 149,000 new cases and 51,000 deaths associated with colorectal
cancer (3). African Americans have greater incidence and mortality
from colorectal cancer than whites, with the greatest racial differences
occurring among women. While incidence declined among white women and mortality
decreased among both white men and women during the 1973 to 1991 period,
rates among African Americans rose. The incidence of colorectal cancer increased
36.1% among African American men yet only 3.0% among white men. Mortality
rose 25.1% among African American men but decreased 11.2% among white men
during the same period. The disparities increase with age. African Americans
are more likely to be diagnosed at a later stage of disease than whites
for both colon and rectal cancers (13). The rate of survival is worse
for African Americans than for whites and, in general, did not increase
during the years 1983 to 1990, a period during in which survival rates among
whites improved.
Risk factors for colorectal cancer that might explain some of the racial
differences are diet, alcohol consumption, physical activity, exogenous
hormone exposure, parity, genetic susceptibility, cancer genotype, and smoking
(14,15). A combination of prevention regimes may present the best
opportunity to lower rates among African Americans and reverse diverging
racial trends.
Lung
Lung cancer accounted for 14% of all cancer cases and 28% of all cancer
deaths in the United States during 1994, with an estimated 172,000 new cases
and 153,000 deaths (Table 1) (3). African American men have significantly
higher incidence and mortality rates than white men.
Tobacco use was recognized nearly 40 years ago as the leading risk factor
for lung cancer (16). Cigarette smoking patterns explain some of
the racial differences. With the exception of young women, African Americans
generally have higher smoking rates than whites (Table 2). Recent investigations
of genetic polymorphisms and lung cancer found no racial differences in
the prevalence of alleles for cytochrome P450 2E1 (17) but did find
differences in allelic frequency for L-myc, p53, and CYP1A1
genes (18-20). Research regarding the role of these genetic differences
in lung cancer etiology is under way. Socioeconomic factors may also explain
some of the racial variation in lung cancer (21). Differential environmental
and occupational exposures may also may explain a portion of the lung cancer
excess. There is some evidence that African Americans disproportionately
reside or work in areas exposed to industrial chemicals (2,22).
Breast
Breast cancer is the most common invasive cancer among women, representing
32% of all new cancer cases and 18% of cancer deaths in the United States
(3). Since 1988, breast cancer has been the leading cause of death
in the United States for women between 40 and 55 years old. In 1994, there
were approximately 182,000 breast cancer cases diagnosed and 46,300 deaths
(Table 1) (3). Although white women are diagnosed more often with
breast cancer than African American women, mortality rates are higher among
African American women. While there has been little to no increase in breast
cancer mortality among whites, African American women have experienced a
20% increase from 1973 to 1991. On average, African American women are diagnosed
in later stages than white women, and have less improvement over time (23).
Age-specific, 5-year relative survival rates are nearly 15% lower among
African American women than white women (Table 3).
Breast cancer risk factors that have been investigated as possible explanations
for the racial variation include socioeconomic factors (21,24), reproductive
patterns (25-28), hormones (29-32), lifestyle (33,35),
health care access (35-37), age (38), proximity or contact
with pesticides (39), diet (40), and genetic susceptibility
(41,42).
One of the earliest analysis of factors associated with stage at diagnosis
for breast cancer among African American and white women was conducted by
the National Cancer Institute's African American/White Cancer Survival Study
Group (43). It assessed in a single study the relationship of sociodemographic,
behavioral, clinicopathologic, and health care access factors to variations
in stage at diagnosis of breast cancer among African American and white
participants. The results indicated that some factors associated with stage
at diagnosis are differentially expressed in African Americans and whites.
Among African Americans only, the investigators observed that access to
health care, lifestyle, and other antecedent medical experiences influence
disease stage at diagnosis. These findings suggest that the advanced
stage of breast cancer at diagnosis is related in part to the poorer access
to health care common to socioeconomically disadvantaged populations.
Addressing essentially the same issue, Lacey (44) identified
several barriers to breast cancer prevention and early detection for urban,
low-income African American women, including: a) other urgent life
priorities, b) financial restrictions related to cost, c)
quality of available health resources, d) limited knowledge regarding
cancer, e) relatively few available sources of information regarding
cancer prevention and detection, and f) poor adherence with follow-up
recommendations. This study found no evidence that African American women
belonging to lower socioeconomic classes were disinterested in their health
or less likely than whites to participate in health promotion activities.
The 5-year survival differences among women with the same stage disease
suggest that the clinical course of the disease is different among African
American women (45). As with other cancers, age modifies risk,
and African American mortality rates decline below those found among whites
above age 69 (3).
Uterine Cervix
Cancer of the uterine cervix is the third most common malignancy of the
female reproductive system in the United States (3). The incidence
among African American women is approximately twice that found among white
women--14.0 per 100,000 women compared to 7.8 per 100,000 women, respectively
(3). This disparity is evident primarily among women age 65 and over,
with African American women experiencing nearly 3 times the incidence of
white women during the years 1987 to 1991 (41.8 per 100,000 women compared
to 15.3 per 100,000 women) (3). African American mortality rates
(6.7 per 100,000) have been about 3 times that among whites (2.6 per 100,000),
which is also primarily attributed to the excess incidence of cervix cancer
among African American women age 65 and over (3). Between 1973 and 1991,
the incidence of invasive cervical cancer decreased for both African Americans
and whites by 55.1 and 35.4%, respectively. This has not been a steady decline
over the time period, and it has differed by both race and age. Most of
the decline in the incidence of invasive cervical cancer observed among
white women occurred during the 1970s and early 1980s. The decline in incidence
has been relatively steady among African American women, with some evidence
of a possible slowing or plateauing in the rate of decrease during the mid
1980s.
Cervical cancer is generally detected later among African Americans than
whites. Between 1983 and 1990, 39% of invasive cervical cancers among African
Americans were detected while the disease was localized (i.e., confined
to the cervix uteri) compared to 53% for whites (3). These differences
in incidence rates by race are evidenced among younger and older women.
In women under 50 years of age, 52% of the invasive cervical cancers detected
in African American women were diagnosed at the localized stage compared
to 67% among white women. Among women 50 years of age and older, 27% of
the invasive cervical cancers diagnosed among African American women were
localized, as were 36% detected among white women (3). Five-year
survival rates are lower among African Americans (56.4%) than whites (69.9%),
with little change over the last two decades (3).
Several factors may have stymied attempts to reduce these disparities,
including the failure among women with abnormal Pap smear results to seek
follow-up care. Poor, uninsured, single, and young women are least likely
to follow recommendations regarding follow-up care. Individuals with abnormal
Pap test results are usually referred to another facility for treatment.
These facilities are often located farther away than the facility of initial
diagnosis and may necessitate an additional appointment, which requires
the individual to miss more time at work. Cost may also act as a barrier.
A pelvic examination that includes a Pap test can cost $100 or more; a fee
that may not be covered by health insurance plans, which often provide little
preventive coverage.
Sexually transmitted human papilloma virus infection is the primary risk
factor for most cases of cervical dysplasia and carcinoma, although other
etiologic factors are probably involved (46). Providing effective
barriers to infection during sexual intercourse, as well as health education,
could reduce the incidence of cervical cancer among women of both racial
groups. Improved access to health care may reduce mortality among African
American women and improve survival rates associated with this preventable
cancer.
Prostate
Prostate cancer is the most commonly diagnosed malignancy and the second
highest cause of cancer-related deaths among men in the United States, accounting
for 32% of new cancer cases and 13% of cancer deaths (Table 1) (3).
Prostate cancer is a disease primarily of older men; it is uncommon below
55 years of age. Incidence increases rapidly with age to more than 1000
cases per 100,000 individuals among men over 75 years of age.
Although the incidence and mortality rates associated with prostate cancer
are higher among African Americans than whites in the United States, there
are wide variations in the incidence of prostate cancer among African populations
(47). In Nigeria and the Caribbean, prostate cancer incidence is
much lower than among African Americans. This suggests that migration and
accompanying changes in environmental conditions may have affected prostate
cancer risk among African Americans (48).
Prostate cancer is biologically heterogenous in presentation and outcome.
It remains latent in some men but intensively aggressive in others. The
proportion of early curable prostate cancer has increased (49). In
1990, African American men were more likely to be diagnosed with stage IV
(29.3%) prostate cancer than white men (17.8%). African American men had
poorer 5-year survival (66.4%) than white men (81.3%) (3). This corresponded
to a greater prevalence of advanced prostate cancer among African American
men. Whether this difference could be explained by differences in urinary
obstructive symptoms was investigated by Brawn et al. (50). They
concluded that survival, stratified by stage and grade, was not affected
adversely by obstructive symptoms. Neither racial differences in the incidence
of obstructive symptoms nor the frequency with which obstructive symptoms
required surgical correction explain the later stage at diagnosis found
among African American men. Presentation at a later stage was almost twice
as common among rural African Americans as among urban African Americans,
suggesting a possible role for socioeconomic factors and access to health
care (51).
The etiology of prostate cancer has not been well characterized and many
unresolved issues remain. Some investigations have indicated that individuals
with prostate cancer tend to consume more dietary animal fat than those
not diagnosed and, therefore, a vegetarian lifestyle may reduce risk (48).
Prostate cancer has also been linked to a history of venereal disease, having
multiple sexual partners, and some occupations, primarily farming and jobs
involving exposure to cadmium (48). In one study of prostate cancer
in the southeastern United States, farming accounted for 38% of the geographic
difference in prostate cancer mortality rates among African Americans (52).
Detailed studies of specific agricultural exposures and prostate cancer
among African American men have not been conducted to date. Vasectomy has
been identified as a potential risk factor for prostate cancer in some
studies but not in others (53). In any event, vasectomy cannot explain
the excess risk among African Americans, because the prevalence of vasectomy
is much lower among African Americans than whites (53). Tobacco use
does not appear to be associated with prostate cancer nor does it explain
the racial disparities (54).
A rapidly evolving interest in familiar aggregation of prostate cancer
has expanded the base of evidence supporting family history as a risk factor
for this disease. A hospital-based study found a 2-fold elevated risk among
men who had a father or brother with carcinoma of the prostate (55).
The risk increased to 6.1 if both a first-degree and second-degree
relative were affected. Other studies have noted similar trends of increasing
risk with increasing numbers of affected relatives. For example, men with
two or three first-degree relatives had a 5-fold and 11-fold increased
risk of prostate cancer, respectively, compared with persons without a family
history of the disease (56-58). Family history and genetic susceptibility
may play a role in the racial differences in incidence rates associated
with prostate cancer.
The higher mortality among African
American men also suggests the role of other factors in determining stage
of cancer at diagnosis, such as delay in seeking health care, demographic
variables, socioeconomic status, functional status, and social support.
Among African American men, there is evidence to link delays in seeking
health care with less favorable disease outcome. Analysis of the Surveillance,
Epidemiology and End Results (SEER) program data from Detroit shows that
increases in cancer detection were less among African
American men at the same time that increases in detection trends were being
recorded for other segments of the population (59). Similar evidence
was found in the 1990 National Cancer Data Base report (49), where
there were large differences in the proportion of advanced cancers diagnosed
among African American and white men. The authors concluded that "Regrettably,
not all segments of the population at risk are benefiting from early
detection of prostate cancer."
Bladder
Urinary bladder cancer accounts for 78,800 new cases and 21,900 deaths
each year in the United States (3). African Americans have lower
incidence of bladder cancer than whites (Table 1), but the 5-year relative
survival is lower among African Americans diagnosed with this type of cancer
than among whites (Tables 3,4). The higher incidence among whites is primarily
due to excess localized tumors, whereas the incidence of more advanced tumors
is similar among both racial groups (60). These data suggest that
whites are more likely to be diagnosed with conditions that go undetected
among African Americans and are less likely to progress to more extensive
disease. Among both African Americans and whites in one large case-control
study, smoking accounted for most of the bladder cancer risk (48 and 43%,
respectively) (60). Workers in high-risk occupations involving exposure
to dyes, rubber, leather, ink, or paints accounted for 22% of cases among
African Americans and 28% of cases among whites. History of bladder infection
was linked to approximately twice as much disease among African Americans
as whites (15% compared to 8%).
Multiple Myeloma
There are approximately 12,700 new cases and 9800 deaths from multiple
myeloma annually in the United States (Table 1) (3). The incidence
and mortality of multiple myeloma are approximately 2-fold greater among
African Americans than whites. With a largely unknown etiology and the highest
world-wide incidence rates occurring among African American African descendants,
investigators struggle to identify risk factors (61). Studies of
occupational exposures (62), human leukocyte antigens (63),
and chronic antigenic stimulation (64) have not been found to explain
the disparities between African Americans and whites.
Conclusion
Available data suggest that there continue to be differences by race
in the incidence and mortality for common types of cancers. Studies of these
patterns suggest etiologic factors and have led to the identification
of probable causes. These factors, however, generally fail to satisfactorily
explain the racial differences in incidence and mortality rates. This may
be due to the inappropriate use of race and ethnicity as surrogates for
social and economic status. It may be easier to use race as a surrogate
for social and economic status than to identify a person of color who has
limited resources, lives in a substandard residential environment, works
in a high-risk occupational setting, or is a single parent exposed to multiple
risk factors--psychological, physiological, or both. Focusing on the poor
surrogate of race, however, may limit the sensitivity of our research.
There are racial biologic variations and within-race individual differences,
both inherited and acquired. These differences may modify various phases
of the multistage process of carcinogenesis such as the capacity to convert
procarcinogens to carcinogens, to detoxify carcinogens, and to repair DNA.
Future progress in untangling the multifactorial dimensions of African
American/white differences in cancer burden must move beyond traditional
epidemiologic methods. Cancer risk characterization must include more emphasis
on biological evaluation of qualitative interindividual differences in susceptibility.
This approach can be enhanced by significant advances that have been
achieved in the molecular, genetic, and biologic aspects of the more common
types of cancers.
The intense activity of those studying the molecular and genetic aspect
of human cancer undoubtedly will generate further advances in the identification
and characterization of cancer risk. Thus, it does not seem overly optimistic
to suggest that approaches that combine clinical, epidemiological, and molecular
research ultimately will illuminate more clearly the primary and secondary
determinants of racial/ethnic differences in cancer incidence and mortality.
The results of this research in conjunction with lifestyle changes, socioeconomic
parity, and environmental equity, has the potential to bring about the most
effective prevention and control strategies to relieve African Americans
of their disproportionate share of the cancer burden.
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