Cad . Saúd e Púb lic a, Rio de Jane iro , 14(Sup. 3):187-191, 1998
Significant contribut ing causes of cancer
deaths among Hispanics in Colorado,
USA, 1983-1992
Causas q ue c o ntrib ue m p ara ó b ito s p o r c ânc e r
e m latino s no Co lo rad o , EUA, 1983-92
1 C o l o ra d o St at e Un i ve r s i t y, D e p a rt m en t of En v i ro n m e n t a l He a l t h . Fo rt Col lin s, C o l o ra d o 805 23 U .S.A. Ki m b e rley Sw e i t z er 1 L o ra n n St a llo n es 1
Abstract Ca n cer d ea t h s in t h e st a t e of Co lora d o, U . S . A . , t ot a led 53,921 b et w een 1983 a n d 1992. D ea t h cert i fica t es fo r t h i s p erio d w ere u sed t o ev a lu a t e Hi sp a n i c ca n cer d ea t h s by con t ribu t i n g ca u ses of d ea t h a n d p rim a ry occu p a t ion o f t h e deced en t . Th e re l a t i ve risk s for d ia bet es an d li ve r d i sea se a s con t ribu t in g ca u ses of d ea t h w ere si gn i fica n t ly h i gh er a m on g Hi sp a n i cs w h en com -p a red t o n on -His-p a n ics w h o h ad a lso d ied o f ca n cer (RR for d ia bet es = 1.90; 95% C.I. ( 1 . 6 4 , 2 . 1 9 ) a n d RR for liv er d isease = 1.44; 95% C.I. ( 1 . 2 3 , 1 . 6 8 ) ) . Hisp an ics w h o h a d d ied o f ca n cer w ere sign ifica sign t ly less lik ely to h a ve dru g a bu se a s a cosign t ribu t isign g ca u se of d ea t h w h esign com p a red t o sign o sign -Hisp a n ics (RR for d ru g ab u se = 0.69; 95% C.I. ( 0 . 5 2 , 0 . 9 1 ) ) . La b o re r s , s e rv ice w ork e r s , a n d clerical w o rk ers w h o w ere Hi s p a n i c ,w e re sign ifica n t ly m ore lik ely to d ie of ca n cer w it h eit h er d iabetes o r l i ver d isea se a s a co n t ribu t in g ca u se of d ea t h t h a n w ere n on -Hisp a n ics in t h e sa m e occu p a t ion al c a t e g o ry (p <0.05). C h ro n ic disea ses, su ch a s d ia bet es a n d liv er d isea se, m a y be red u cin g t h e su r-v i r-v a b ilit y of ca n cer a m on g Hi s p a n i c s .
Key words N e o p l a s m s ; Ca u se of D e a t h ; Di f f e ren t ia l M o rt a l i t y ; Hisp an ic Am e r i c a n s
Resumo En t re 1983 e 1997, o c o r re ra m 53.921 óbit os p or câ n cer n o Est a d o d o Colora d o, E UA . Os a t est a do s d e óbit o p a ra est e p erío d o fo ra m u t i liz a d o s p a ra a v a lia r a s ca u sa s qu e co n t ribu í ra m p a ra a m ort e e a ocu p ação p rin cip a l do s óbit os p or câ n cer o corrid os em la t in os n est e p eríodo. Os ri scos re l a t i vos p a ra d ia bet es e d oen ça h ep á t i ca co m o cau sa s a ssocia d a s a o ób it o f o ra m sign ifi-c a t i v a m en t e m a i o res em la t in os, ifi-c o m p a ra t i v a m en t e ifi-com n ã o la t in os qu e t a m b ém f a leifi-cera m co m câ n cer (d i a b et es RR = 1 ,90; I . C . 95% 1,64 -2,1 9; d o en ça h ep á t i ca RR = 1,44; I . C . 95% 1,231 , 6 8 ) . O con su m o de d roga s co m o ca u sa a ssocia d a à m o rt e en t re la t in os qu e falecera m p o r câ n -cer a p a ren t o u ser sign ifi ca t i v am en t e m en or qu e em n ã o la t in os (RR = 0,69; I . C . 95% 0,52-0,91). Op e r á r i o s , s e rv i d o res p ú b licos e t ra b a l h a d o res d e escrit óri o d e o rigem la t i n a t en d era m a a p resen t ar d ia bet es e doen ça h ep á t ica co m o cau sa s associa d a s à m ort e p or cân cer em m a io r fre q ü ê n -c i a , est a t i st i -ca m en t e si gn i f i-ca t i va , q u e n ã o l a t i n o s n o s m esm os ra m o s d e a t i v id a d e (p <0,05). Do en ça s crôn ica s, co m o d ia bet es e doen ça h ep á t ica , p odem est a r red u z in do a sobrev id a p or câ n -cer em la t in os.
SW EITZER, K. & STALLO NES, L.
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Cad. Saúd e Púb lic a, Rio d e Jane iro , 14(Sup. 3):187-191, 1998 I n t ro d u c t i o n
Ca n c e r d a t a fo r Co l o ra d o Hisp a n ic s re ve al a n i n t e re st in g p a ra d ox (Ka rp e t a l., 1991; Fin ch e t a l., 1997). Alt h o u gh t h e o ve r a ll c a n ce r in c i-d e n ce rat e fo r H isp a n ic s is low e r t h a n t h a t fo r An glo s (Ta b le 1), Hisp a n ics h ave fe we r ca n ce r s u rv i vors aft er five yea rs ( Ta b le 2). Su rv i va l ra t e is lowe r fo r H isp a n ic s fo r a ll s t a ge s o f in it ia l c an ce r d ia gn o sis ( Ta b le 2). Th e in c id e n c e t o -m o rt a lit y ra t e ra tio s fo r Co l o ra d o Hisp a n ics in 1995 we re a pp roxim a t e ly e q u a l to t h o se o f An glo s ( Ta b le 3). H owe ve r, h ist o r i c a l l y, t h e se ra -t ios ha ve b ee n so m e wh a-t lowe r ( Ta b le 3).
Som e c a n c e rs h a ve s h own st rikin gly in c rea se d rat e s a m on g Co l o ra d o Hisp an ics com -p a re d t o t h e ir An glo c o u n t e r-p a rt s ( Ta b le 4). Am o n g t h e se ca n ce rs is ce rvica l ca n ce r, wh ich h a s alm o st t wic e t h e in c id e n ce ra t e a m o n g Co l o r ad o Hisp a n ic wo m e n com p a re d t o An glo wo m e n ( Ta b le 4). Ca n ce rs o f t h e st o m a ch , liv-e r, ga llb la d d liv-e r, la ryn x, a n d kid n liv-e y h a vliv-e liv-e lliv-e va t-e d in c id t-e n ct-e ra t t-e s a m o n g H isp a n ic s o f b o t h se xe s ( Ta b le 4).
Th e ob jective of t h is re s e a rch wa s to loo k at c o m p lic a t in g m e d ic a l fa ct o r s wh ic h c on -t r ib u -t e d -t o -th e ca n ce r d e a -th s o f Co l o rad o H i s-p a n i c s. Th e h ys-p o t h e sis was t h a t som e c h ro n i c m e d ic al co n d it io n s m a y b e re d u c in g t h e five -ye a r su rv i va l ra te fo r H isp a n ics wh o h a ve b e en d iagn osed w ith ca n ce r.
M e t h o d o l o g y
Co l o ra d o d e a t h ce r t ific at e d a t a fo r t h e ye a r s 1983 t h ro u gh 1992 we r e o b t ain e d fro m t h e He alt h St at is t ics Se c t io n o f t h e Co l o ra d o De p a r tm e n t o f Pu b lic He a lt h a n d t h e En v i ro n -m e n t . Resid en ts a n d n o n re sid en ts o f Co l o ra d o wh o h a d d ie d in t h e s t a t e d u rin g t h e t e n - ye a r p e riod we re in clu d ed in th e d at a se t. To e n su re co m plet e re sid e n t d at a , a n in t er st a te e xc h a n g e o f d e a t h ce rt ific a t e in fo rm a t io n h as b e e n u t i-l i zed b y th e st at e of Co i-l o ra d o. T h e re f o re t h e d a-t a se a-t a ls o in clu d e d Co l o ra d o re s id e n a-t s w h o d ied in o th e r Sta t es d u r in g t h e t en -ye a r p e ri o d ( Co l o ra d o De p a r tm e n t o f He alt h , 1990).
Th e e n t ire d a t a s e t fo r t h e t e n -ye a r p e r i o d w a s e va lu a t e d fo r c a n c e r a s a n u n d e rlyin g or a t t r ib u t a b le ca u se of d e at h , u sin g t h eIn t e r n a-t i on a l Cla ssi fica a-t ion of Di s e a s e s(U .S. De p a rt -m en t of Heath an d Hu -m an Services, 1991) cod es 1400-2399. Th e u n d e rlyin g ca u se o f d e a t h wa s d e fin e d a s t h e d ise a s e o r in j u r y t h a t in it iat e d t h e e ve n t s le a d in g d ire ct ly t o d e a t h (Co l o ra d o De p a r t m e n t o f He a lt h , 1990). An a t t ri b u t a b l e c a u se o f d e a t h w a s d e fin e d a s a ll t h o se d
is-e a s is-e s, m o r b id co n d it io n s, o r in ju riis-e s t h a t is-e i-t h e r re s u li-t e d in o r co n i-t rib u i-t e d i-t o i-t h e d e a i-t h ( Co l o rad o De p a rt m en t of H ealth , 1990).
Fo r d e at h s wit h can ce r a s an u n d e rlyin g o r a t t r ib u t a b le c a u se, a ll co d e s fo r a d d it io n a l cau ses we re ta b u lat ed . T h e re we re a m axim u m of e le ve n co d e s p e r d e a t h c e rt ifica t e d e sc ri b -in g t h e m e d ica l d ia gn os is a n d e n viro n m e n t a l ca u se o f th e d e at h . Sele cte d a tt rib u t a b le ca u s-es of d e at h wh ich we re o f in te re st in clu d e d : al-co h o lis m (al-co d e s 3030-3039); d iab e te s (c o d e s 2500- 2509); h e a rt d is e a se (c o d e s 4010-4299); d ru g a b u se (co d e s 3050- 3059); live r d is e a se (c o d e s 5700- 5739); a n d in ju ry (c o d e s 8000-9999). Mo re t h an o n e cau se o f d e a th was list ed
Tab le 1
*All canc e r site s incid e nc e rate s pe r 100,000 Co lo rad o re sid e nts in 1995 b y Hisp anic e thnic ity.
Ethnic gro u p M a l e s F e m a l e s
A n g l o 4 3 6 . 0 3 3 9 . 0 H i s p a n i c 3 6 9 . 0 2 7 6 . 0
* Canc e r in Co lo rad o Co lo rad o De partme nt o f He alth 1 997.
Tab le 2
*All canc e rs 5-ye ar re lative survival rate s in Co lo rad o 1984 -198 8 b y stag e at d iag no sis and e thnicity.
S t a g e A n g l o s H i s p a n i c s
All stag e s 5 3 % 4 4 % L o c a l i z e d 8 5 % 7 5 % R e g i o n a l 5 7 % 5 1 % D i s t a n t 1 5 % 1 3 %
*Cance r in Co lo rad o Co lo rad o De p artm e nt o f He alth 1 991.
Tab le 3
* I n c i d e n c e - t o - m o rtality rate ratio s in Co lo rado b y e thnic ity.
E t h n i c i t y / g e n d e r 1 9 9 1 - 1 9 9 3 1 9 9 5
Ang lo male s 2 . 8 2 . 5 Hisp anic male s 2 . 6 2 . 5 Ang lo fe male s 2 . 6 2 . 7 Hisp anic fe male s 2 . 5 2 . 7
Cad. Saúde Púb lic a, Rio d e Jane iro , 14(Sup . 3):187-191, 1998
o n a p p ro xim at e ly 65% o f all d e a t h ce rt i f i c a t e s d u rin g th is p e ri o d .
In s t r u c t io n s o n t h e St a t e of C o l o ra d o Ce r-tificate of De a t hfor lin e 10a re g a rd in g o ccu p a-t ion a re a s follows : “De c e d e n t’s U su a l Oc c u p a -t i on – giv e k in d of w ork d o n e d u rin g m os-t o f w o rk in g life – do n ot u se re t i re d” (Co l o ra d o De p a r t m e n t o f He a lt h , 1990:275). Th is in fo r m a -t io n was a va ila b le fo r -t h e e n -t ire -t en -ye a r p e r io d . Blu e cio lla r wio rke r ca t e gio r ie s w e re t h e io c -cu p a tion al gro u p s o f in t ere st. Th e fo llowin g oc-cu p a t io n a l ca t e go ry co d e s we re u s e d : s e r v i c e w o rke rs we re id en t ifie d usin g t h e o ccu p at io n al co d e s 433 t o 469; la b o re r s h a d o c cu p a t io n a l co d e s 863 t o 889; a n d co d e s 303 t o 389 d efin e d c l e rica l wo rke rs (Co l o ra d o De p a r t m e n t o f He a lt h , 1989). T h e s e o cc u p a t io n a l c a t e go r i e s a re t h e 1980 St a n d a rd Occu p a t io n a l Classifica -t io n c od e e q u iva le n -t s (Co l o r a d o D e p a r-t m e n -t o f He a lt h , 1989).
His p a n ic o rigin w as a va ria b le in clu d e d in t h e d e a t h ce r t ific at e d a t a . Et h n ic or igin s in -clu d ed in th e Hisp an ic ca te gory we re : Me x i c a n ; Pu e rt o Rica n ; Cu b an ; Ce n t ra l an d Sou th Am e r-ican ; a n d o th e r a n d u n kn own Sp a n i s h .
Th e d a t a s e t wa s st r a t ifie d a n d t a b u la t e d u sin g St a t g ra p h ics Plu s versio n 7 (Ma n u g i s t i c s, 1995). Tw o - by-t wo tab les we re an a lyze d fo r re
l-a t i ve risk e st im l-a t es l-an d 95% co n fid e n ce in t e r-vals u sin g Ep i In fo ve r sio n 5 (Ce n t e r s fo r Di s-e a ss-e Co n t ro l, 1991).
R e s u l t s
Ca n c e r d e a t h s in Co l o ra d o b e t we e n 1983 an d 1992 t o ta le d 53,921. Of t h ese d ea t h s, 3,203 h a d H is p a n ic o r igin d e s ign a t e d o n t h e d e a t h c e r -t i f i c a -t e. Th e ove ra ll Re l a -t i ve Risk (RR) o f d e a -t h f ro m c a n ce r fo r Hisp an ics co m p a re d t o n o n -His p an ics a m on g all ca u se s o f d e a t h wa s 0.82. Th e 95 p e rce n t co n fid e n ce in t e r va l (95% C.I.) fo r t h is risk was 0.80 t o 0.85.
H is p a n ic s wit h ca n ce r a n d d ia b e t e s list e d a s ca u se s o f d e a t h t o t a le d 169 ( Ta b le 6). No n -H isp a n ics wit h b ot h d ia b e te s an d can ce r list ed a s c a u se s o f d e a t h t o t ale d 1,357. Th e RR for H isp a n ic s h a vin g b o t h ca u se s o f d e a t h , w h e n c o m p a re d t o n o n - H isp a n ic s w h o a ls o d ie d o f b o t h ca u se s, w as 1.90 (1.64,2.19) a s sh ow n in Ta b le 6.
Ne it h e r h e ar t d ise a se o r a lc o h o lism wa s fo u n d to b e a sign ifica n t co n t rib u t in g ca u se o f d e a t h fo r Hisp a n ic c a n ce r p at ie n t s ( Ta b le 5). Dru g ab u s e, a s a c o m p lic a t in g c au se o f d e a t h a m o n g Co l o ra d o Hisp an ic ca n ce r vict im s, wa s
Se le c te d c anc e r site s with hig he r c ance r inc id e nc e rate s amo ng Hisp anic p o p ulatio n in the State o f Co lo rad o , U.S.A., 1 991-19 93.
Cancer sit e A n g l o s H i s p a n i c s
M a l e
Co lo n and re c t u m 4 2 . 3 5 8 . 8 S t o m a c h 8 . 1 1 4 . 6 L i v e r 2 . 6 5 . 3 G a l l b l a d d e r 0 . 5 2 . 4 P a n c re a s 1 0 . 1 1 2 . 4 K i d n e y 1 1 . 9 1 7 . 2 L a ry n x 5 . 6 6 . 5 F e m a l e
C e rv i x 7 . 4 1 4 . 0 S t o m a c h 3 . 5 8 . 3 L i v e r 1 . 6 3 . 2 G a l l b l a d d e r 1 . 0 2 . 7 L a ry n x 1 . 4 2 . 1 K i d n e y 6 . 6 8 . 7 T h y ro i d 7 . 6 1 0 . 8
* Canc e r in Co lo rado , Co lo rad o De p artme nt o f He alth, 1997. Rate s p e r 100,000 Co lo rado re s i d e n t s .
Re lative risk fo r Hispanics o f canc e r d e ath, c o mplic ate d b y se le c te d d ise ase s and hazardo us e xpo sure s, State o f C o lo rado , U.S.A. , 19 83-1 99 2.
Comp licat ing diseases H i s p a n i c N o n - H i s p a n i c R R 9 5 % - C I for cancer deat hs
D i a b e t e s
P re s e n t 1 6 9 1 , 3 5 7 1 . 9 0 1 . 6 4 - 2 . 1 9 A b s e n t 3 , 0 3 4 4 8 , 9 0 5
H e a rt disease
P re s e n t 7 3 1 1 2 , 1 5 0 0 . 9 3 0 . 8 6 - 1 . 0 1 A b s e n t 2 , 4 7 2 3 8 , 1 1 2
A l c o h o l i s m
P re s e n t 1 2 1 5 1 1 . 2 1 0 . 6 6 - 2 . 3 1 A b s e n t 3 , 1 9 1 5 0 , 1 1 1
D rug ab use
P re s e n t 5 0 1 , 1 5 2 0 . 6 9 0 . 5 2 - 0 . 9 1 A b s e n t 3 , 1 5 3 4 9 , 1 1 0
Liver disease
P re s e n t 1 4 8 1 , 5 9 4 1 . 4 4 1 . 2 3 - 1 . 6 8 A b s e n t 3 , 0 5 5 4 8 , 6 6 8
I n j u ry
SWEITZER, K. & STALLO NES, L.
1 9 0
Cad. Saúde Púb lica , Rio de Jane iro , 14(Sup . 3):187-191, 1998
Tab le 6
Re lative risk* fo r Hisp anic s o f c ance r d e ath, c o mplic ate d b y se le c te d dise ase s and hazard o us e x p o s u re s, b y o c c upatio nal g ro up s in the state o f Co lo rad o , U.S.A., 1983-1992 .
D i s e a s e s R R* 95% CI
Liver d isease
Cle rical wo rke rs 2 . 1 5 1 . 0 7 - 4 . 3 2 L a b o re r s 1 . 7 0 1 . 1 9 - 2 . 4 1 S e rvic e wo rke rs 1 . 7 3 1 . 0 1 - 2 . 9 4 D i a b e t e s
Cle rical wo rke rs 2 . 4 7 1 . 1 8 - 5 . 1 6 S e rvic e wo rke rs 1 . 8 4 1 . 1 4 - 2 . 9 6
* Co mpare d to no n-Hisp anic c anc e r d e aths amo ng tho se in the sam e o c c up atio nal g ro u p .
sign ifican tly re d u ce d in risk co m p ared to n o n -H is p a n ics ( Ta b le 5). Live r d is e as e h a d a RR o f 1.44 a n d w a s a s ign ifica n t co n t rib u t in g ca u s e o f d e a t h for H isp a n ics wh o h a d d ie d of c a n c er ( Ta b le 5). In j u r y wa s n o t a sign ifican t ly d iffe r-e n t r isk fa ct o r fo r Hisp a n ics wh o h a d d ir-e d o f c a n c e r, co m p ared t o n o n -Hisp an ics ( Ta b le 5).
Wh en select ed b lu ecollar occu pa tio n a l c a t -e g o r i-e s w-e r-e -e va lu a t -e d b y c an c-e r d -e a t h a n d H isp a n ic o rigin , t h e a fo rem e n t io n e d a t t ri b u t -in g ca u se s o f d ea t h e m e rge d a s sign ifican t fac-t o r s. Fo r H is p a n ic la b ore rs a n d s e r vic e a n d c l e rical wo rke rs wh o h ad d ied o f ca n cer, th e RR o f live r d ise a se a s a co m p lica t in g fa c t o r wa s sign ific an t wh e n c o m p a re d t o n o n -Hi s p a n i c s wh o h a d also d ied o f ca n ce r a n d h a d th e sa m e o cc u p a t ion ( Ta b le 6). Wh e n o t h e r jo b c a t e -g o rie s we re e va lu a t e d b y Hisp a n ic e t h n icit y a n d ca n c e r d e a t h , live r d ise as e wa s n o t a sig-n ifica sig-n t fa c t o r. Masig-n y o f t h e 20 o c cu p a t io sig-n al c a t e g o r ie s th a t we re evalu ate d by Hisp an ic et h -n icit y a -n d ca -n ce r d e a th a lso h a d d iab e t e s a s a sign ific an t risk fact o r. In c lu d e d in t h e se o ccu -p a t io n a l c a t e go rie s we r e cle rica l an d s e r v i c e w o rke rs ( Tab le 6).
D i s c u s s i o n
Th e e xp la n a t io n fo r Co l o ra d o H isp a n ics h a v-in g b o t h fe we r c a n ce r s a n d re d u c e d ca n c e r s u rv i va l is like ly a n in t e ra ct io n o f m a n y fa c -t o r s. Th is re s e a rch in d ica -t e s -t h a -t d iab e -t e s a n d l i ve r d isea se sign ifica n tly co n trib u t e t o ca n ce r d e a th s in Hi s p a n i c s.
Blu e co lla r wo rke rs we re o f sp e cial in t e re s t b e ca u se re s e a rc h h a s sh ow n t h a t wit h in e ac h e t h n ic se gm e n t in t h e Un it e d St a t e s (U .S.) th o se in d ivid u a ls a re a t in cre ased r isk o f d ea t h ( So rlie e t a l., 1995). A n u m b e r of a u t h o rs h ave re p o rt e d sign ifica n t ly in c re a s e d ra t e s o f d ia -b e t e s a m o n g H is p a n ic re sid e n t s in t h e U .S. ( Fle gel et al., 1991; Sa m e t e t a l., 1988; Baxt e r et al., 1993). Gi ven t he se two sit u a tio n s, it wa s in -t e res-tin g -to fin d -th a-t d iab e -te s wa s n o -t a sign ifi-ca n t risk fo r Hisp an ic la b o re rs wh o h a d d ied o f c a n c e r, ye t wa s a s ign ifica n t r isk fo r m a n y of t h e wh it e co lla r ca t e go r i e s. In c re a se d ra t e s of c h ro n ic live r d ise ase a m o n g U.S. m ale Hi s p a n -ics h as b e e n re p o r t e d (Po le d n ak, 1995), b u t is le s s st u d ie d t h an d ia b e t e s in H i s p a n i c s. It is t h e re f o re an im p o rt a n t re su lt t h at ch ron ic live r d ise ase wa s a sign ifican t risk facto r fo r Hi s p a n -ic b lu e co lla r wo rke rs w h o h a d d ie d o f c an ce r (Tab le 6). Th is is m a d e m o re in t erest in g b y th e fin d in g th a t o n l yt h e s ele ct e d b lu e c o lla r c a t e -g o ries h a d ch ron ic live r d ise ase a s a si-gn ifica n t risk fa ct or. Be ca u se t h e Hisp a n ic can cer d ea th s we re com p ared to n o n -Hisp an ics wh o ha d also d ie d o f ca n ce r a n d we re in t h e sa m e o ccu p a -t io n a l c a-t e go ri e s, -t h is fin d in g su gge s -t s -t h a-t t h e re m a y b e som e in t era ct io n b et w ee n a low-e r s o cio low-e c on o m ic s t a t u s (SES) a n d Hi s p a n i c e t h n ic it y t h a t re s u lt s in c h ro n ic live r d is e a se a n d can cer.
C o n c l u s i o n s
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