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November 15, 2007 / Volume 110 / Number 10

Cancer registrars rely on information available in medical and administrative records for race/ethnicity information; this information often is not available or is not collected and recorded in a systematic man- ner. Several recent reports have recommended that hospitals implement a uniform framework for the collection of data concerning race, ethnicity, and lan- guage, including a rationale for reporting these data, providing scripts and developing other tools to facili- tate data collection.161 Another approach to improve race classification further for AI/AN is the develop- ment and expansion of tribal rosters, such as the Northwest tribal roster,25 to complement the IHS patient registration database and thereby increase the usefulness of data linkages.

The high rate of misclassification of AI/AN race on death certificates has been documented in several studies.27,162 Although the cancer mortality data pre- sented in this report were not linked to the IHS patient registration database to address racial mis- classification and likely are underestimates, the de- velopment of linkage protocols for death certificates is in progress for addressing this challenge in future reports.

Improved surveillance data advance cancer con- trol and guide future research to address gaps in knowledge. The AI/AN population has high incidence rates of several cancers for which some risk factors are modifiable, such as cigarette smoking, alcohol consumption, obesity, infectious agents (H. pylori and several viruses—hepatitis B, hepatitis C, and human papillomavirus), and possibly diabetes. To reduce cancer burden in AI/AN populations, specific cancer prevention and control interventions should be targeted accordingly and tailored to their special needs. In addition, the generally lower cancer screen- ing rates for AI/AN provide a compelling case for enhanced cancer screening programs for AI/AN populations in all regions. Regional geographic varia- tions for the AI/AN populations are important when developing cancer control policies for these popula- tions. AI/AN often live in remote communities with limited access to prevention services and unfavorable socioeconomic conditions, factors that further com- plicate successful cancer control programs. Deliver- ing cancer screening and other preventive services in these communities hinges on innovative and cultu- rally appropriate interventions. National and local cancer control partners should work with tribes to develop such demonstration projects and to explore other research needs (eg, identifying causes of the disproportionately high rates of colorectal cancer in Alaska and the Northern Plains, examining the deter- minants of low breast cancer rates in AI/AN women

in the Southwest, or evaluating the association of di- abetes to patterns of colorectal and other cancers in AI/AN populations).

Cigarette smoking remains the single most im- portant behavioral risk factor for cancer. This is espe- cially true for the AI/AN population, in which the use of both cigarettes and smokeless tobacco are substantially higher than in any other racial or ethnic population in the U.S.163 Although American Indians have cultivated and used tobacco since pre-Colum- bian times, the recreational or habitual use of com- mercial tobacco products is a relatively recent phenomenon. Many AI/AN individuals still use tobacco as part of traditional ceremonial or healing practices, so tobacco cessation programs must adopt culturally appropriate approaches. There are some tobacco control activities under way, such as the tribal tobacco centers funded by the CDC Office on Smoking and Health and tobacco cessation clinics in a few IHS and tribal clinics. These activities have been rather limited, however; and, until this problem is addressed with substantial resources, further increases in the incidence of lung cancer and other tobacco-related cancers can be expected in the AI/ AN population.

AI/AN populations must have improvements in access to high-quality cancer treatment. Achieving this will require changes in the healthcare delivery system for AI/AN. Few IHS and tribal facilities have specialized cancer care capabilities. Many AI/AN patients must travel long distances at substantial expense for clinic appointments or for scheduled treatment. AI/AN patients who are unfamiliar with the healthcare system are bewildered by the com- plexity and confusion of specialty cancer care. Expansion of initiatives such as the patient navigator programs could greatly improve access of AI/AN patients to needed preventive and treatment services.

This report emphasizes the importance of ana- lyzing regional cancer incidence data for the AI/AN population to interpret a national picture which, by conveying overall lower AI/AN cancer incidence rates, creates the impression that cancer is not a pri- ority for the AI/AN population. In keeping with what was noted in last year’s report regarding the Hispanic population, subgroup analysis is essential to under- stand those differences—by region in the case of the AI/AN population—and to develop appropriate inter- ventions. Information on geographic variation in cancer rates for NHW, non-Hispanic black, and His- panic populations is available widely through the dissemination of state incidence and death rates in such publications as the United States Cancer Statis- tics, Cancer in North American from the NAACCR,

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