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Cancer Survival Among US Whites and Minorities
A SEER (Surveillance, Epidemiology, and End Results) Program Population-Based Study
Limin X. Clegg, PhD;
Frederick P. Li, MD;
Benjamin F. Hankey, ScD;
Kenneth Chu, PhD;
Brenda K. Edwards, PhD
Arch Intern Med. 2002;162:1985-1993.
ABSTRACT
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Background Available cancer statistics pertain primarily to white and African American
populations. This study describes racial or ethnic patterns of cancer-specific
survival and relative risks (RRs) of cancer death for all cancers combined
and for cancers of the colon and rectum, lung and bronchus, prostate, and
female breast for the 6 major US racial or ethnic groups.
Methods Cancer-specific survival rates were analyzed for more than 1.78 million
patients who resided in the 9 SEER (Surveillance, Epidemiology, and End Results)
Program geographic areas and were diagnosed between 1975 and 1997 as having
an incident invasive cancer, by 6 racial or ethnic groups (non-Hispanic whites,
Hispanic whites, African Americans, Asian Americans, Hawaiian natives, and
American Indians and Alaskan natives).
Results Survival rates improved between 1988 to 1997 for virtually all racial
or ethnic groups. However, racial or ethnic differences in RRs of cancer death
persisted after controlling for age for all cancers combined and for age and
stage for specific cancer sites (P<.01). African
American, American Indian and Alaskan native, and Hawaiian native patients
tended to have higher RRs of cancer death than the other groups. American
Indians and Alaskan natives generally exhibited the highest RRs of cancer
death, except for colorectal cancer in males.
Conclusions Survival rates in patients with cancer have improved in recent years,
but racial or ethnic differences in survival rates and in RRs of cancer death
persist. Additional studies are needed to clarify the socioeconomic, medical,
biological, cultural, and other determinants of these findings.
INTRODUCTION
CANCER IS the second leading cause of death in the United States, and
it accounts for approximately one fourth of all deaths. In 2002, an estimated
1.28 million Americans will be diagnosed as having cancer (other than carcinomas
of the skin), and 555 500 people will die of cancer.1
The most common cancers in men are of the prostate, lung (including bronchus),
colon and rectum, whereas women are most likely to develop carcinomas of the
breast, lung, colon, and rectum.
United States cancer incidence and survival data are collected on a
routine basis from population-based cancer registries that participate in
the SEER (Surveillance, Epidemiology, and End Results) Program of the National
Cancer Institute. Published SEER Program data show that for most cancers,
including the 4 major ones (colorectal, lung and bronchus, female breast,
and prostate), the survival rate in African American patients was poorer than
that in white patients, although survival rates improved in recent years for
both groups.2 Information is limited on patient
survival in other racial or ethnic minorities.
The survival measure used in this study quantifies the likelihood that
a patient with cancer will not die of the neoplasm within a specified time
after diagnosis. The survival rates presented herein use population-based
data and, therefore, are less affected by referral patterns and other sources
of bias that might be associated with hospital-based case series.
This article describes and compares cancer-specific survival rates and
relative risks (RRs) of cancer death in patients diagnosed as having a first
malignant neoplasm between January 1, 1975, and December 31, 1997, in 9 SEER
Program areas. The cancers included in the study are all cancers combined
and 4 major cancers: female breast, colorectal, lung (including bronchus),
and prostate. We used the SEER Program data in which patient race or ethnicity
was recorded into 1 of the following groups: non-Hispanic white, Hispanic
white, African American, American Indian or Alaskan native, Chinese, Japanese,
Filipino, Hawaiian native, other, and unknown. The analyses presented include
2 periods (January 1, 1975, to December 31, 1987, and January 1, 1988, to
December 31, 1997), and 6 major US racial or ethnic groups: non-Hispanic whites,
Hispanic whites, African Americans, American Indians and Alaskan natives,
Asian Americans (Chinese, Japanese, and Filipino), and Hawaiian natives. These
6 groups contributed approximately 99% of the cases throughout the 1975 to
1997 period. The focus of the analysis is on racial or ethnic patterns of
survival for patients diagnosed in the recent period (1988-1997). Changes
over time in patient survival are also examined.
PARTICIPANTS AND METHODS
STUDY POPULATIONS AND DATA SOURCES
The SEER Program currently collects cancer incidence and survival information
from 10 population-based cancer registries that encompass nearly 14% of the
total US population. This study used the data from 9 geographic areas that
have been included in the SEER Program since 1975 (Connecticut, Hawaii, Iowa,
New Mexico, and Utah and the metropolitan areas of Atlanta, Ga; Detroit, Mich;
Seattle–Puget Sound, Wash; and San Francisco–Oakland, Calif).
Based on 1990 census data, these 9 SEER Program areas cover more than 9% of
the US population; the percentages by race are 9% of US non-Hispanic whites,
8% of Hispanic whites, 9% of African Americans, 29% of Asian Americans (Chinese,
Japanese, and Filipino), 14% of American Indians, and 66% of Hawaiian natives.
This study included 1 779 458 patients in the 6 racial or
ethnic groups who resided in the 9 SEER Program geographic areas, were diagnosed
as having a first invasive cancer during 1975 to 1997, and were followed for
vital status through December 31, 1998. The analyses focused on cancer-specific
survival rates and on RRs of cancer death for all cancers combined and for
cancers of the breast (females only), lung (including bronchus), prostate,
and colorectal. These 4 cancers accounted for more than 50% of all incident
cancers diagnosed in the SEER Program areas during these years.2
Approximately 5% of patients were lost to follow-up before January 1, 1999.
Excluded from the study were patients with cancer who died of unknown causes
(n = 36 932), those whose initial diagnosis was found on the death certificate
or at autopsy (n = 29 282), and those who were not being actively followed
(n = 3). Cancer site and morphology were coded according to the International Classification of Diseases for Oncology, Second Edition;
cancers with histologic codes 9590 through 9989 (extranodal lymphomas) within
each of the 4 cancer sites were excluded.2
CANCER STAGING
Cancer stage was determined by the extent of cancer spread from the
site of origin at initial diagnosis. The SEER Program staging scheme classified
invasive cancers into 4 stages: localized to the primary tumor site, tumor
with regional spread, tumor with distant metastases, and unknown (when relevant
data were unavailable or when stage was assigned >4 months after initial diagnosis).
Data on cancer stage were included for breast, colorectal, lung, and prostate
cancers. For prostate cancer, local and regional stages were combined because
these 2 stages were no longer distinguishable in the SEER Program staging
scheme after American Joint Committee on Cancer staging practices were changed
in 1995.3 For lung cancer, a coding change
associated with the presence of pleural effusion for patients diagnosed after
January 1, 1988, resulted in these patients being staged as having distant
disease rather than localized or regional disease.4
This change increases the number of patients coded as having distant stage
disease. Therefore, analyses of trends in lung cancer survival rates over
time were precluded.
STATISTICAL ANALYSIS
The statistical significance of racial or ethnic differences, by sex,
in distributions over potential prognostic factors at diagnosis was assessed
using  2 tests of associations. The 2 prognostic factors considered
were cancer stage and age category (<50, 50-54, 55-59, 60-64, 65-69, 70-74,
and >74 years). All tests of significance were performed separately by sex
and by cancer site.
The Kaplan-Meier estimator5 was used
to estimate cancer-specific survival rates. Deaths attributed to causes other
than the underlying cancer were treated as losses to follow-up at the date
of death under the assumption that deaths from the underlying cancer were
independent of deaths from other causes. Therefore, a cancer-specific survival
rate, for example, the 5-year cancer-specific survival rate, provides an estimate
of the likelihood of surviving 5 years if cancer is the only cause of death.
Survival times were measured in months and were censored at the date of a
patient being lost to follow-up (about 5%), the date of death from causes
other than the underlying cancer, or on December 31, 1998 (whichever occurred
first).
When comparing survival for patients diagnosed in 1975 to 1987 with
those diagnosed in 1988 to 1997, survival times were censored at 5 years to
provide equal duration of follow-up. Five-year survival rate was chosen as
a conventional survival statistic that could be reliably estimated and compared
for the 2 periods.
For the later period of diagnosis (1988-1997), survival curves by race
or ethnicity are presented. The maximum possible follow-up was approximately
11 years (131 months); however, the survival curves were plotted only up to
the last follow-up time when at least 1 cancer death occurred. The survival
curves did not start from 100% because some patients died within a month of
diagnosis, which resulted in "zero" survival time because only month and year
were used for the calculation.
Relative risks (hazard ratios) of cancer death (by cancer type and sex)
were used to access racial or ethnic differences in cancer survival for patients
diagnosed during 1988 to 1997 with up to 11 years of follow-up. The RRs were
calculated using the Cox regression model to adjust for age at diagnosis for
all cancers combined and for age and tumor stage for each cancer site examined.6 To avoid the strong assumption of proportional hazards,
the baseline hazards were stratified by age and stage (ie, stratified Cox
model). Indicator variables for each racial or ethnic group were introduced
into the stratified Cox model, with non-Hispanic whites as the reference group.
The assumption of proportional hazards for race or ethnicity was checked by
graphing the log of the negative log of the survival functions vs the log
of time for each racial group. Plotted lines were roughly parallel over time
and were inferred to show proportionality.
Stratified Cox models (by age for all cancers combined or by age and
stage for each common cancer site) were also used to assess racial or ethnic
changes in survival rates at 5 years over time, by cancer type and sex, for
patients diagnosed during 1975 to 1987 and those diagnosed during 1988 to
1997. Because of the 1988 changes in the staging classification for lung cancer,
changes in survival during the 2 periods for lung cancer were not assessed.
Indicator variables for the 2 periods and the racial or ethnic groups, and
interactions between these periods and race or ethnicity, were introduced
as covariates into the stratified Cox model. Assumptions of proportional hazards
for period of diagnosis were checked in the same manner as for race or ethnicity. P values from Wald 2 tests were used to
assess the statistical significance of changes in survival rates between 1975
to 1987 and 1988 to 1997 for each of the racial or ethnic groups after taking
into account the significance of interaction terms between period and race
or ethnicity. These comparisons were made by sex for all cancers combined
and for each of the 4 cancers studied. All tests were 2-sided. Statistical
software (SAS version 6; SAS Institute Inc, Cary, NC) was used for all analyses.
RESULTS
There were 917 021 eligible males (51.5% of all patients) and 862 437
eligible females (48.5%) diagnosed as having an incident malignant cancer
in the 9 SEER Program areas in 1975 to 1997 (Table 1). Approximately 54% of the patients were diagnosed as having
the following cancers: lung or bronchus (n = 248 741), colorectal (n
= 225 104), female breast (n = 258 562), and prostate (n = 233 520).
Non-Hispanic whites accounted for 84% of all patients with cancer, whereas
African Americans accounted for 9%, Hispanic whites for 3%, Asian Americans
for 3%, Hawaiian natives for less than 1%, and American Indians and Alaskan
natives for less than 1%.
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Table 1. Invasive Cancers Diagnosed by Sex, Primary Cancer Site, and
Race or Ethnicity for the 9 SEER Program Areas, 1975-1997*
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Table 2 gives the distributions
of cancer stage by race or ethnicity and period of diagnosis (1975-1987 or
1988-1997) for cancers of the prostate, breast (females), colon, rectum, and
lung in both sexes combined. The differences in distribution of stage by period
were statistically significant for all racial and ethnic groups for each of
the 3 cancers for which comparisons could be made (P<.001
for all). The increases in the percentage of patients with distant stage lung
cancer in 1988 to 1997 reflected changes in SEER Program coding practices
for lung cancer in 1988, and, therefore, these percentages should not be compared
for the 2 periods. The percentage of patients with distant stage colorectal,
breast, and prostate cancer declined over time for each racial or ethnic group,
except for colorectal cancer in Hispanic whites and American Indians and Alaskan
natives and breast cancer in American Indian and Alaskan native and Asian
American women. For patients diagnosed during 1988 to 1997, American Indians
and Alaskan natives had the highest percentages of distant stage cancer of
the lung, breast, and prostate; American Indians and Alaskan natives and African
Americans had the highest percentages of distant stage colorectal cancer.
In addition, distributions by age at diagnosis differed by race or ethnicity
for each of the 4 major cancer sites and for all cancers combined (P<.001 for all) (data not shown). Non-Hispanic whites and Asian
Americans tended to be diagnosed as having cancer at older ages than the other
racial or ethnic groups, possibly in part because of their longer life expectancy.
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Table 2. Stage Distributions for Primary Cancers of the Lung or Bronchus,
Colorectal, Prostate, and Female Breast by Race or Ethnicity and Diagnosis
Period*
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Figure 1 and Figure 2 show sex- and site-specific cancer survival curves for
patients diagnosed during 1988 to 1997. For all cancers combined, cancer-specific
survival rates 5 years after diagnosis were approximately 45% to 60% in males
and 50% to 65% in females in the 6 racial or ethnic groups; thereafter, the
cancer survival curves approached a plateau. Survival curves for colorectal
cancers mimicked those for all cancers combined, whereas lung cancer survival
in both sexes declined rapidly and reached a plateau of 20% at 3 years. Survival
for breast and prostate cancer showed steady declines throughout the first
decade after diagnosis. American Indian and Alaskan native males and females
with cancer had the lowest survival rates for cancers of the breast, lung,
and prostate and for all cancers combined. African Americans had lower survival
rates for colorectal, prostate, and breast cancers. In contrast, Hispanic
whites, non-Hispanic whites, and Asian Americans tended to have the best survival
rates for the cancer sites examined.
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Figure 1. Male survival by race or ethnicity
for all cancers combined (A) and for lung (B), colorectal (C), and prostate
(D) cancers. Surveillance, Epidemiology, and End Results Program, 1988-1997.
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Figure 2. Female survival by race or ethnicity
for all cancers combined (A) and for lung (B), colorectal (C), and breast
(D) cancers. Surveillance, Epidemiology, and End Results, 1988-1997.
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Table 3 gives adjusted RRs
of cancer death for male and female patients diagnosed during 1988 to 1997
for the 4 cancers studied and for all cancers combined. Non-Hispanic whites
are the reference group in all comparisons. The overall test for racial or
ethnic differences in risk of cancer death was statistically significant for
each cancer site and for all cancers combined (P<.01
for all). The RRs for every minority group other than Asian Americans were
statistically significantly higher for each of the 4 cancers and for all cancers
combined. Asian American males and females had the lowest RRs for each of
the 4 cancers (RR, 0.73-0.93), and Asian American females also had the lowest
RR for all cancers combined. In contrast, American Indians and Alaskan natives
of both sexes had the highest RRs for all cancers combined (adjusted RRs,
1.7 for males and 1.8 for females) and for most of the 4 common cancers (adjusted
RRs, 1.1-2.0). Exceptions were a higher RR for colorectal cancers in African
American males (RR, 1.2; 95% confidence interval, 1.2-1.3) and an equally
high RR for breast cancer in African American females (RR, 1.6; 95% confidence
interval, 1.6-1.7).
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Table 3. Adjusted Relative Risk (RR) of Cancer Deaths for Patients
Diagnosed in 1988-1997 and 5-Year Cancer-Specific Survival Rates for Both
Periods, by Cancer Type, Race or Ethnicity, and Sex*
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Table 3 also gives 5-year
race- and sex-specific survival rates for patients diagnosed during 1975 to
1987 and 1988 to 1997 and changes in these rates between the 2 periods. The
statistical significance of the differences in improvements in survival across
the racial or ethnic groups over time for each cancer was assessed by testing
for interactions between diagnosis period and racial or ethnic group based
on the stratified Cox model. All tests for evidence of an interaction were
significant (P<.10 for all comparisons), except
for colorectal cancer (P>.10 for all comparisons).
The significance of these tests was accounted for when comparing survival
rates over time for each racial or ethnic group. The changes in survival for
lung cancer were not tested because the 1988 changes in coding practices affect
stage. Men and women in all 6 racial or ethnic groups had significantly improved
survival rates in the later period for all cancers combined (P<.01 for all comparisons). Survival rates for Hispanic and non-Hispanic
whites, African Americans, and Asian Americans with breast, colorectal, or
prostate cancer were also improved significantly (P<.01
for males and females in each racial or ethnic group). Significant improvements
in survival rates were observed for American Indians and Alaskan natives with
breast or prostate cancer and for males with colorectal cancer. Survival rates
for Hawaiian native females with breast cancer also improved significantly
(P<.01), but they also had a nonsignificant decrease
in the 5-year survival rate for colorectal cancer (P
= .53).
COMMENT
Data from the SEER Program were analyzed to study racial or ethnic patterns
in cancer-specific survival and RRs of cancer death by sex. Our results update
and extend previously published studies7-10
that focused largely on whites and African Americans and provide first-known
population-based comparisons of RRs of cancer death and cancer-specific survival
among the 6 major US racial or ethnic groups. This study was facilitated by
the intentional coverage by the SEER Program of certain geographic areas with
relatively large racial or ethnic population subgroups so that some information
on the cancer burden would be available for these groups.11
Although geographic areas included in the SEER Program were not selected randomly,
they include various levels of urbanization and socioeconomic status. Thus,
descriptive studies based on SEER Program data, which cover large percentages
of the populations being studied, provide insights at the national level.
Relative risks of cancer death and cancer-specific survival rates improved
for the 6 racial or ethnic groups of patients with cancer diagnosed during
1988 to 1997 compared with those diagnosed during 1975 to 1987. However, the
extent of improvement varied by race or ethnicity. Racial or ethnic differences
in RRs of cancer death were found for patients diagnosed during 1988 to 1997
after controlling for age and stage for each of the 4 common cancers and age
only for all cancers combined. In this period, non-Hispanic white, Hispanic
white, and Asian American patients of both sexes tended to have lower adjusted
RRs of cancer death than African Americans, American Indians and Alaskan natives,
and Hawaiian natives. American Indians and Alaskan natives had the least favorable
adjusted RRs of cancer death for all cancers combined and for each of the
individual cancers examined compared with non-Hispanic whites, except for
male patients diagnosed as having colorectal cancer. However, the numbers
of American Indian and Alaskan native and Hawaiian native patients were small,
and their survival rate estimates might be less stable than those for larger
racial or ethnic groups. The finding that Asian American patients of both
sexes had the lowest adjusted RR of cancer death (except for all cancers combined
in male patients) merits additional study because the deaths would not be
recorded in the United States if patients returned to their homeland for family
support or terminal care.
Differences in access to and utilization of effective cancer screening
and treatment services by race or ethnicity might explain some of our findings.
Mammography screening has been shown in randomized clinical trials12-13 to reduce breast cancer mortality
rates, especially in women 50 years and older. In the 1994 National Health
Interview Survey,14 62% of female respondents
(aged  50 years) reported mammography screening in the past 2 years, a
substantial increase from 27% in 1987. Our analysis of the public use data
from the 1998 National Health Interview Survey indicated that the 2-year mammography
screening rate for the group 50 years and older has increased to 69%; the
findings by race or ethnicity were 70% for non-Hispanic whites, 67% for African
Americans, 63% for Asian Americans and Pacific Islanders, 61% for Hispanic
whites, and 51% for American Indians and Alaskan natives. The lower mammography
screening rate and the observed small fraction of localized breast cancers
found for American Indian and Alaskan native female patients could partly
explain their relatively low survival rates.
For 1988 to 1997, despite minor differences in their reported mammography
screening rates in 1998, a smaller percentage of African American patients
were diagnosed as having localized breast cancer compared with non-Hispanic
whites (52% vs 63%), and they also had a 60% higher adjusted risk of breast
cancer death than non-Hispanic whites. This finding might account in part
for breast cancer mortality rates being higher in African American women than
white women diagnosed during 1990 to 1996 in the SEER Program population15 and the entire US population.14
One explanation is that screening benefits in African American women have
not yet been realized because decreases in breast cancer mortality rates due
to screening lag behind increases in mammography utilization.
Other possible explanations for the observed racial or ethnic differences
in RRs of cancer death include differences in access to optimal treatments
that reduce cancer mortality rates. Some studies16-18
have reported that as many as 30% to 50% of minority women with abnormal mammography
findings did not receive timely follow-up. Low socioeconomic status, lack
of health insurance, and low literacy can also delay diagnosis and reduce
access to optimal therapies.19-22
Unfavorable adjusted RRs of cancer death in American Indians and Alaskan natives
and Hispanics might also be explained by cultural factors, such as reliance
on only traditional health care providers.23
In addition, unmeasured biological determinants of breast cancer survival
might partly explain our findings. Nuclear atypia, high histologic grade,
increased fraction of S-phase cells, and necrosis have been reported24 as unfavorable prognostic factors more often associated
with breast cancers in African American women compared with those found in
white women. Mutations in the p53 gene also differ among the races, and certain
p53 gene mutations might be independent predictors of lower survival among
African Americans but not whites.25-26
The lowest RRs of breast cancer death for Asian American women might be mediated
by constitutional factors.27
Recent US guidelines28-30
recommended that persons 50 years and older and at average risk for colorectal
cancer undergo 1 or more of the following screening tests: fecal occult blood
testing annually and sigmoidoscopy every 5 years, colonoscopy every 10 years,
or double-contrast barium enema every 5 to 10 years. Randomized clinical trials31-34 have
demonstrated that fecal occult blood testing decreases mortality rates of
colorectal cancer among those aged 50 to 80 years. Our analysis of the 1998
National Health Interview Survey indicated that non-Hispanic whites (aged 50
years) had the highest fecal occult blood testing rates (37% for males and
36% for females). The rate was 35% for American Indian and Alaskan native
males but only 17% for American Indian and Alaskan native females (sample
sizes were small). Assuming that relatively little fecal occult blood testing
was done during 1975 to 1987 in American Indians and Alaskan natives, the
sex difference in recent screening patterns probably contributed to the temporal
increases in colorectal cancer survival rates among American Indian and Alaskan
native males but not females.
Prostate cancer screening by digital rectal examination, transrectal
ultrasound, or serum prostate-specific antigen (PSA) is controversial because
of the lack of definitive evidence of benefit, although some observational
studies suggest a benefit.35 Uncertainties
regarding optimal treatment of localized cancers have added to the controversy.36-41
However, subsequent to the introduction of the PSA test in 1986 to monitor
disease status in patients with prostate cancer, the incidence of prostate
cancer increased dramatically, apparently owing to use of the PSA test for
diagnosis and screening rather than for disease monitoring only. Increases
in prostate cancer survival rates for patients diagnosed during 1988 to 1997
are likely due in part to lead-time bias, overdiagnosis, and a benefit from
screening if screening using the PSA test is, in fact, efficacious. In this
study, increases in prostate cancer survival rates over time were observed
for all racial or ethnic groups.
Screening and treatment for lung cancer have done little to improve
disease outcomes. Randomized controlled trials have yet to demonstrate that
screening with radiography, sputum cytology, or helical (spiral) computed
tomography reduces lung cancer mortality rates.42-43
Presently, smoking cessation and prevention programs represent the best strategies
for reducing lung cancer mortality rates. To date, the survival data observed
for lung cancer by race and sex indicate little change over time.
Welch et al44 recently criticized the
use of improvements in 5-year survival rates over time as a valid measure
of success against cancer. Lead-time bias, length bias, and overdiagnosis
from screening can create the appearance of an improvement in 5-year survival
rates when none has occurred. These authors44
advocated the use of population-based cancer mortality rates over time as
the gold standard for assessing progress against cancer, and we do not disagree
with them. Because population estimates are not available for several of the
racial or ethnic groups examined in this study, it is not possible for us
to calculate population-based mortality rates for them.
There is little doubt that our data reflect lead-time bias and length
bias, particularly for prostate cancer. Also, the differential effect of screening
over time due to variation in screening rates is a confounder when analyzing
temporal changes in survival rates in diverse racial or ethnic groups. We
recognized that changes in survival over time might be confounded by the differential
effects of various early interventions, and our analyses focused on racial
or ethnic patterns in survival for the later period. It is recognized that
survival measures for 1988 to 1997 are also potentially confounded by the
differential effects of cancer control interventions, although our results
are consistent with SEER Program data15 showing
that during 1990 to 1996 African Americans had higher population-based mortality
rates than whites for most major cancer sites other than lung cancer.
Our analysis used cancer-specific survival rather than relative survival,
which is used in National Cancer Institute publications on cancer statistics.2 Relative survival is the ratio of observed all-cause
survival to expected survival as obtained from US life tables for selected
periods.45 However, reliable expected life
tables are not available for Hispanic whites, Hawaiian natives, American Indians
and Alaskan natives, and Asian Americans to generate valid relative survival
estimates. To obtain reliable estimates of cancer-specific survival rates
it is essential that classification of the underlying cause of death on death
certificates is accurate. For colorectal, lung, breast, and prostate cancers,
levels of accuracy exceed 90% for the underlying cause of death,46
although it is conceivable that cause of death accuracy may vary based on
health care access issues. In addition, cancer-specific survival rates are
consistent with population-based cancer mortality rates, which are also based
on the underlying cause of death.
Limitations of our study include the relatively small number of cancers
diagnosed in some minorities, particularly American Indians and Alaskan natives
and Hawaiian natives. In addition, our analyses only controlled for age and
tumor stage at diagnosis because data were not available for other potential
prognostic factors, such as socioeconomic status, comorbid diseases, and health
insurance status. Nevertheless, our study results are consistent with previous
studies showing lower breast cancer survival rates for African American women
compared with white women after controlling for prognostic factors such as
age and tumor stage, menopausal status,47 socioeconomic
status,48-50 Medicaid/Medicare
status,48 tumor size,47-49
histologic grade,48-49 lymph node
status,47 or hormone receptor status.47 Other researchers51
have also found that Asian American women with breast cancer have higher survival
rates compared with white women after controlling for age, tumor stage, and
histologic grade. For prostate cancer, our data are consistent with a health
maintenance organization–based study51
that showed poorer survival among African Americans compared with whites after
controlling for age and tumor stage.52
In summary, this study provides the first known population-based data
on cancer-specific survival rates and RRs of cancer death for the 6 major
racial or ethnic groups in the United States. Additional research is needed
to clarify the role of socioeconomic, medical, biological, cultural, and other
determinants of racial or ethnic differences in survival rates for patients
with cancer described in this article.
AUTHOR INFORMATION
Accepted for publication January 31, 2002.
This research was funded in part by grant U01CA86322 from the National
Institutes of Health, Bethesda Md, and by a Harry and Elsa Jiler American
Cancer Society Clinical Research Professorship (Dr Li).
We thank Otis Brawley for his helpful discussions during the early stage
of this research and David Annett for his assistance with creation of the
data file.
Corresponding author and reprints: Limin X. Clegg, PhD, National
Cancer Institute, National Institutes of Health, 6116 Executive Blvd, MSC
8316, Suite 504, Bethesda, MD 20892-8316 (e-mail: lin_clegg{at}nih.gov).
From the Surveillance Research Program, Division of Cancer Control
and Population Sciences (Drs Clegg, Hankey, and Edwards), and the Center to
Reduce Cancer Health Disparities (Dr Chu), National Cancer Institute, Bethesda,
Md; and the Department of Adult Oncology, Dana-Farber Cancer Institute, Boston,
Mass (Dr Li).
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