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rent report permits presentation of regional rates only for the Southern Plains for women and the Southwest for women and men. Elevated rates in the AI/AN population may be related to a high preva- lence of cholelithiasis,117,118 a strong risk factor for

gallbladder cancer, and obesity.119

Recent declines in

gallbladder cancer incidence rates in AI/AN popula- tions in the Southwest most likely are because of increasing use of laparoscopic cholecystectomy in this region. 120

Previous reports have documented high inci- dence rates of stomach cancer among AI/AN popula- tions in many areas96,121,122; and, in the current report, incidence rates for stomach cancer among AI/AN persons were consistently higher than those for NHW persons in Alaska, the Northern and South- ern Plains, and the Southwest. In recent years, chronic infection with H. pylori has emerged as a key factor in the development of gastric cancer 123 and several studies have documented high prevalence of H. pylori infection in Native communities. Tobacco smoking, alcohol abuse, and obesity—with a higher prevalence among AI/AN than NHW popula- tions—also are associated with an elevated risk of stomach cancer, especially gastric cardia adenocarci- noma.125–127 Additional research is needed to charac- terize the combination of risk factors that place AI/ AN persons at higher risk of this disease. 112,124

Although liver cancer incidence is increasing in most race/ethnic populations in the U.S., it was ele- vated consistently in AI/AN men and women com- pared with NHW men and women for the period 1999 through 2004. Alcohol-related morbidity varies across AI/AN communities but remains a significant health concern for many tribal groups.35,128,129 Before the introduction of hepatitis B vaccination, chronic hepatitis B virus infection was endemic among AI/ AN persons in Alaska.130 Alcohol abuse and viral hepatitis have a synergistic, positive association with liver cancer and are likely contributors. Furthermore, in 2002, the proportion of deaths attributable to chronic liver disease, a significant risk factor for liver cancer, was 4 times greater in AI/AN populations compared with U.S. white populations. 131

Healthcare for American Indians and Alaska Natives This study reports less favorable socioeconomic sta- tus and healthcare access for AI/AN groups com- pared with NHW groups. Having a usual source of care is a key predictor of cancer screening and other preventive services46; and consistent with this, the cancer screening prevalence for AI/AN populations is lower compared with the prevalence for NHW popu- lations.

Report to the Nation, 19752004/Espey et al.


Previous studies have documented that AI/AN populations have been diagnosed disproportionately with late-stage disease and have relatively poor 5-year survival compared with other populations.7,132–137 The findings in this report are consistent with previ- ous studies, indicating that AI/AN populations may not have benefited from available screening technol- ogies and generally have more late-stage diagnoses than NHW populations. These observations in AI/AN populations have led to the development of cultu- rally appropriate screening programs in many regions.138–141 Although data are limited on factors that may be associated with later stage at diagnosis among AI/AN populations, studies in other racial groups suggest that stage differences among popula- tions may be influenced by awareness of cancer symptoms, access to a regular healthcare provider, and adequacy of follow-up for abnormal screening







abnormal test result and receiving a definitive dia-


Despite persistent disparities, remark-

able progress has been made in cervical cancer control.144

The IHS provides primary healthcare to approxi- mately 1.8 million enrolled members of federally recognized tribes of the estimated 3.3 million AI/AN in the U.S.145 The 150 IHS hospitals and clinics are located primarily on reservation lands and in a few cities with relatively large AI/AN populations. Half of these healthcare facilities are managed by tribal gov- ernments under negotiated agreements with the fed- eral government, and half are operated directly by the federal government. An additional 34 urban health centers receive some federal funding to pro- vide healthcare to urban AI/AN. Eligible AI/AN peo- ple can receive free healthcare at any IHS facility, but a complex set of rules governs and restricts delivery of contract health services for specialty medical care, such as cancer treatment, which generally is not available in IHS facilities. AI/AN people who do not live within the CHSDA counties, who do not have access to an IHS facility, or who receive non-IHS health benefits may not receive any health benefits from IHS. Funding for IHS is by Congressional appropriation and currently is at the level of $2532, compared with $5645 per capita personal medical

services for U.S. citizens.146

Lower funding for IHS,

combined with remote rural residence, may contri- bute to the lack of primary care even in the CHSDA counties. Geographic, financial, and bureaucratic barriers to receiving appropriate cancer treatment as well as cultural beliefs also may contribute to poor survival rates among AI/AN persons.

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