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Gustavo D. Cruz, DMD, MPH, Christian R. Salazar, MPH and Douglas E. Morse, DDS, PhD

Gustavo D. Cruz, Christian R. Salazar, and Douglas E. Morse are with the Department of Epidemiology and Health Promotion, New York University College of Dentistry, New York, NY.

Correspondence: Requests for reprints should be sent to Gustavo D. Cruz, DMD, MPH, New York University College of Dentistry, Department of Epidemiology and Health Promotion, 345 East 24th Street, New York, NY, 10010. (e-mail: gustavo.cruz{at}nyu.edu)

	ABSTRACT

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Objectives. We investigated whether oral cavity and pharyngeal cancer (OPC) incidence and mortality statistics among Hispanics in New York State differed from those among Hispanics in the United States as a whole.

Methods. OPC incidence and mortality statistics for 1996–2002 were obtained from the New York State Cancer Registry and compared with national statistics released by the Surveillance, Epidemiology, and End Results (SEER) program for the same period.

Results. Among Hispanic men, OPC incidence rates were approximately 75% and 89% higher in New York State and New York City, respectively, than national rates reported by the SEER program. No notable differences were identified among Hispanic women. Incidence rates among New York State Hispanic men were 16% higher than those of their non-Hispanic White counterparts. The difference was twice as high (32%) among Hispanic men in New York City. Mortality rates among both men and women exhibited patterns similar to the incidence patterns.

Conclusions. Ethnoregional differences exist in the incidence and mortality rates of OPC in the United States. New York State Hispanic men exhibit much higher incidence and mortality rates than US Hispanics as reported by the SEER program.

	INTRODUCTION

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The American Cancer Society estimated 29 370 new cases and 7320 deaths attributable to oral cavity and pharyngeal cancer (OPC) in the United States in 2005.¹ As of 2001, New York State ranked third among all US states in the total number of new cases and in the number of deaths because of OPC.² Each day in New York State approximately 5 people are diagnosed with OPC and at least 1 person dies of the disease.

The etiology of OPC is complex. The primary behavioral risk factors for OPC are smoking and the consumption of alcoholic beverages, and a number of studies report that their joint effect is multiplicative.^3–6 In terms of dietary intake, the most consistent finding has been a protective effect associated with a high consumption of fruits, and a number of studies have also suggested that the consumption of some vegetables may be inversely associated with OPC risk.^7,8 More disparate findings have been reported regarding the relation between OPC and the consumption of bread and grains, dairy products, and poultry as well as meat and fish.⁸ Other risk factors include some human papilloma viruses and sun exposure (for lip cancer).⁹

Although disparities between racial groups (i.e., Black and White) in the incidence and mortality of OPC have been reported, very little is known about differences in morbidity and mortality among Hispanic populations. Recent studies have shown that ethnoregional differences (variations by ethnic background and geographic location) exist in cancer risk factors across diverse Hispanic populations, most probably because of both economic and cultural factors.¹⁰ Furthermore, other studies have shown ethnoregional differences in cancer screening practices among US Hispanics.¹¹

The Hispanic population in the United States has exhibited a dramatic growth in the last decade. According to the latest US Census report, there are more than 41 million Hispanics in the United States, and their numbers are likely to continue to rise because of immigration and high birth rates.¹² Furthermore, US Hispanics are increasingly diverse, coming from more than 20 different countries with various cultural, socioeconomic, and political backgrounds. Geographic variations exist in the composition of the Hispanic population in the United States: Hispanics residing in the West and South are mainly of Mexican origin; those in the Southeast are mainly Cubans, whereas those in the Northeast are mainly Puerto Ricans.¹³ Culturally influenced differences in behavioral risk factors and genetic variations exist among these groups.^14,15 Other differences across these groups include place of birth (United States or foreign born), acculturation status, socioeconomic status, neighborhood composition, access to timely health care, as well as scarcity of culturally appropriate prevention and treatment efforts.^14–16

With the recent expansion of the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program, it is only recently that more comprehensive cancer incidence data for Hispanics have been available at the national level. Over the last decade, these data have identified higher rates among Hispanics for some cancers (e.g., stomach, liver, cervix and gallbladder) and lower rates for others (e.g., OPC) compared with non-Hispanic Whites. Despite these findings, the racial and ethnic diversity that exists among Hispanic subgroups, generally defined by their geographic origin, is an often neglected factor in assessments of cancer morbidity among Hispanics in the United States. Efforts to clearly characterize cancer disparities among Hispanics have been hampered by gaps in coverage that exist in reporting national data.^17,18

An incomplete picture of OPC incidence and mortality among Hispanics in the United States may lead to false assumptions regarding the challenge at hand and result in a lack of culturally appropriate resources to control this disease. To date, no published study has examined the OPC burden among Hispanics in any of the large cities where Hispanics constitute the largest minority.

The aim of our study was to characterize the OPC burden among Hispanics in New York State and New York City and contrast these statistics with national data for US Hispanics reported by the SEER program for the same time period.

	METHODS

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OPC incidence and mortality statistics from 1996–2002 were obtained from the New York State Cancer Registry (NYSCR). These data were compared with those released by the SEER program for the same period.¹⁹ All incidence and mortality rates were age-adjusted to the 2000 US standard population.

The data collected by both registries and utilized for our report were collected and coded in accordance with the Office of Management and Budget.²⁰ The SEER program identifies Hispanic ethnicity by a combination of medical record review and matching surnames against a list of Hispanic surnames.²¹ The information required by the NYCSR including data elements, such as gender, race and ethnicity, is abstracted from each patient’s medical record by a certified tumor registrar. The term Hispanic used throughout our report does not account for racial differences within the Hispanic population. Furthermore, His-panic subgroups are not reported here because the NYCSR does not release information on Hispanic subgroups for OPC. Although the major focus of this study was to compare rates among Hispanics as reported by the SEER program and by the NYCSR, we have included incidence, mortality, and early detection rates among non-Hispanic White individuals to provide context for those comparisons.

Unless otherwise indicated, all references to national data refer to data obtained from the SEER program, and all references to New York City data and New York State data refer to data obtained from the NYSCR.

New York State Cancer Registry
The NYSCR is one of the oldest cancer registries in the country. It has collected information on cancer cases for more than 50 years. The data collected includes the anatomical site of the tumor, the stage at diagnosis, the cell type of the cancer and, more recently, some treatment information. The NYSCR also collects specific demographic information (age, gender, race/ethnicity, residence, place of birth, etc) as well as information about the date and cause of death for persons diagnosed with cancer. The NYSCR participates in the North American Association of Central Cancer Registries (NAACCR) certification process, and as part of this process, the NYSCR submits data annually to be evaluated for timelines, completeness, and quality. The data presented in this report, for diagnosis years 1996 to 2002, met the gold standards for all NAACCR measures of data quality, including overall completeness, percentage of cases with information on key data items (county of residence at diagnosis, race, gender, and age), prevalence of unresolved duplicates, percentage of cases reported from death certificates only, and percentage of cases passing interfield data edits. When the NYSCR updated its database in 1996, it adopted the SEER and NAACCR standards for coding data; thus, beginning with the 1996 data, the registry is fully comparable with both SEER and NAACCR data. All cancer cases diagnosed in 2001 and later are reported using International Classification of Diseases-Oncology, Third Edition²² (ICD-O-3) codes. Cases from 1996 to 2000, which were originally reported using previous editions of ICD-O, have been converted to ICD-O-3. The ICD-O-3 codes for OPC are the same as those used by SEER (C00-C14).

National Cancer Institute SEER Program
The SEER program is a national cancer surveillance database that collects and reports incidence and survival data from a sample of the US population. Data items collected by SEER include demographic characteristics, anatomical and histological characteristics of the specific cancer, stage at diagnosis, diagnostic techniques used, treatment received within 4 months of diagnosis, and patient outcomes.

In the current analysis, OPC incidence rates for 1996–2002 were calculated with SEER*Stat version 6.1.4 software (National Cancer Institute Surveillance Program, Bethesda, Md). Rates among Hispanics (all races) and Non-Hispanic Whites were based upon the following SEER areas: Atlanta, Ga; Connecticut; Iowa; New Mexico; Seattle, Wash; Utah; and Los Angeles, San Jose, and San Francisco–Oakland, Calif. New York State rates were not included in the SEER statistics.

National Center for Health Statistics
Mortality information was obtained from the SEER program as reported by the National Center for Health Statistics. US mortality rates were calculated for all states except Maine, Minnesota, New Hampshire, North Dakota, and Oklahoma, because of a large number of individuals with unknown origin or ethnicity during the relevant period. The "Hispanic Index" as developed by the National Cancer Institute was used to exclude states where the mortality statistics for His-panics were deemed unreliable.¹⁹ New York State and New York City mortality rates were also obtained from that data source for the same time period.

	RESULTS

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Figure 1 shows the age-adjusted incidence rates for OPC over the period 1996–2002, by race/ethnicity and gender, as reported by the SEER program and the NYSCR. Although the rates for New York State include those for New York City, we show the New York City rates separately because the large majority of New York State Hispanics reside in New York City. Among Hispanic men, rates were approximately 75% and 89% higher in New York State and New York City, respectively, than national rates (17.0 per 100 000 per year for New York State; 95% confidence interval [CI] = 15.8, 18.3; and 18.3 per 100 000 per year for New York City; 95% CI = 16.9, 19.8; vs 9.7 per 100 000 per year for the United States as a whole; 95% CI = 9.1, 10.4). No notable differences among His-panic women were noted between OPC incidence rates reported by the NYSCR and those reported by the SEER program.

View larger version (12K): [in this window] [in a new window] [Download PPT slide]   FIGURE 1—— Age-adjusted incidence rates with 95% confidence intervals for cancer of the oral cavity and pharynx by race/ethnicity and gender for the United States as a whole (US), New York State (NYS), and New York City (NYC), 1996–2002. Note. US data are from the National Cancer Institute’s Surveillance, Epidemiology, and End Results program. New York State and New York City data are from the New York State Cancer Registry. Rates were age-adjusted to the 2000 US standard population.

Figure 2 shows age-specific OPC incidence rates, by gender, among Hispanics nationally and in New York State. For all ages, Hispanic men in New York State had higher incidence rates than Hispanic men in the United States as a whole. The difference was greatest among those older than 30 years. Incidence rates among men reached a plateau after about 60 years of age both nationally and in New York State. Rates among Hispanic women were generally similar nationally and in New York State but showed some variation among women aged 30–44 and older than 70 years.

View larger version (18K): [in this window] [in a new window] [Download PPT slide]   FIGURE 2—— Age-specific incidence rates with 95% confidence intervals for cancer of the oral cavity and pharynx among Hispanics by gender for New York State (NYS) and the United States as a whole (US), 1996–2002. Note. US data are from the National Cancer Institute’s Surveillance, Epidemiology, and End Results program. New York State data are from the New York State Cancer Registry. Rates were age-adjusted to the 2000 US standard population.

View larger version (11K): [in this window] [in a new window] [Download PPT slide]   FIGURE 3—— Age-adjusted mortality rates with 95% confidence intervals for cancer of the oral cavity and pharynx by race/ethnicity and gender for the United States as a whole (US), New York State (NYS), and New York City (NYC), 1996–2002. Note. US data are from the National Center for Health Statistics. New York State and New York City data are from the New York State Cancer Registry. Rates were age-adjusted to the 2000 US standard population.

	DISCUSSION

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Ours is the first published report to compare incidence and mortality rates for OPC among Hispanics residing in New York State with national Hispanic rates reported by the SEER program. The results of this analysis show a disproportionately higher incidence of OPC among Hispanic men in New York State than among Hispanic men in the United States as a whole. Among Hispanic men, OPC incidence rates in New York State were almost twice the national rates. In New York City, where the majority of the state’s Hispanics live, incidence rates among men were even higher. The higher incidence of these cancers among New York State Hispanics is apparent for all ages but is most notable among those aged 30 years and older. Furthermore, contrary to national findings from the SEER program, Hispanic men in New York State had much higher incidence and mortality rates for OPC than non-Hispanic White men in New York State. Among women, the New York rates were generally similar to the national rates reported by the SEER program: lower among Hispanics than among non-Hispanic Whites.

Although the limitations of the data do not permit us to elucidate the reasons for the ethnoregional differences in OPC incidence and mortality, it is reasonable to speculate that the observed differences are at least partially because of differences in the populations included under the broad heading of "Hispanic" and their population-specific patterns of risk factor exposure. In most areas where the SEER program collects data on Hispanics, the Hispanic population is composed primarily of Mexican Americans, whereas in New York State the vast majority of Hispanics are of Puerto Rican descent.

Because Puerto Ricans are US citizens, there is a continuous circular migration between the island of Puerto Rico and the US mainland (especially New York City). Interestingly, incidence rates during a similar period among Puerto Ricans residing in Puerto Rico are similar to those seen in New York State.²³ It is also noteworthy that both OPC incidence rates among men living in Puerto Rico, and male:female ratios for OPC incidence in Puerto Rico are among the highest in the Western Hemisphere and much higher than those of US non-Hispanic Whites.²³

In Puerto Rico, smoking tobacco (cigarettes, pipes, and cigars) and drinking alcoholic beverages have been found to account for approximately one half of OPC cases among women and three quarters of those among men.³ A recent case–control study conducted in Puerto Rico showed that the risks were most apparent among those who usually drink liquor straight.²⁴ The same study showed a heritable component to OPC in Puerto Rico, especially among individuals with known risk factors and those who reported a first degree relative with OPC or other cancer of the upper aerodigestive tract.²⁵ It would be interesting to determine if similar patterns are exhibited among Hispanics of Puerto Rican descent living in New York State and in other parts of the United States. New York State’s Puerto Ricans have been reported to not only be more likely to smoke than Mexican Americans, but also more likely to smoke 20 or more cigarettes per day than Mexican American smokers.²⁶ Differences also exist in diet, nutrition, and sun protection among Hispanic subgroups in the US.¹⁰

The comparison of age-adjusted incidence rates by anatomical site across the SEER registry and the NYSCR revealed that for most anatomical sites and with few exceptions, His-panic men in New York State had higher incidence rates than Hispanic men in the United States as a whole. In both registries the tongue was the primary site, followed by the gum and other mouth in New York State, and by tonsil, hypopharynx, and gum in the United States as a whole. It is possible that variations in risk factor exposure patterns among New York State Hispanics may account for the observed differences, but we are unable to ascertain that on the basis of the available data.

Close to 70% and 57% of all OPC in Hispanic men and women, respectively, in New York State are detected at a late stage, compared with approximately 61% and 50% among non-Hispanic White men and women, respectively. The disparities in early-stage diagnosis among male and female Hispanics compared with their non-Hispanic White counterparts may be a reflection of lower OPC awareness among Hispanics or the lower utilization of health services exhibited by Hispanics in the United States.^27,28 A recent study utilizing National Interview Health Survey data showed very low OPC awareness and examination rates among US His-panics compared with non-Hispanic Whites.²⁹ Preliminary data from the 2002 New York State Behavioral Risk Factor Surveillance System confirm those findings in New York State. When we compared the awareness of OPC signs, symptoms, risk factors, the existence of an OPC examination, and OPC examination rates between Hispanics and non-Hispanics in New York State, Hispanics fared far worse in all categories. These data also indicated an underutilization of health care services among those at highest risk for OPC, smokers who engage in risky drinking behavior.

Hispanics in the United States have a substantially lower incidence and mortality from cancers at many anatomical sites (with the exception of stomach, liver, gallbladder, and cervical carcinomas) than do non-Hispanic Whites.¹⁵ Such findings, as well as findings from many other health indicators, have contributed to what is commonly known as the "Hispanic Paradox," whereby Hispanics exhibit similar or better health outcomes than non-Hispanic Whites, despite lower educational and income levels.^30,32 On the other hand, recent studies have suggested that Hispanic Americans tend to experience a cancer burden similar to that seen in their countries of origin.³³ Interestingly, as stated earlier, Puerto Ricans in Puerto Rico experience high rates of OPC, and those rates are very similar to those experienced by Hispanics in New York State.^23,25

If the general assumption is that Hispanics are at low risk for OPC on the basis of relatively low rates reported in national registries, a dearth of OPC awareness programs designed specifically among Hispanics at the local or national level will follow. Although there are several local and national tobacco cessation educational materials and programs designed for Spanish-speaking persons, we were unable to find any published reports regarding programs to increase awareness about OPC signs, symptoms, and risk factors specifically targeted toward Hispanics. Lack of awareness among health care providers, policymakers, and community leaders of the frequency of OPC among Hispanics in New York State may also have led to an underestimation of the risk exhibited by this population and, thus, to the scarcity of prevention and early detection programs in that State.

There is an urgent need to develop and implement culturally appropriate OPC control programs in New York State. Although Puerto Ricans share many of the ethnic, socioeconomic, and cultural characteristics of other Hispanic groups in the United States, they maintain distinguished traits that must be considered when designing OPC control programs for this population. The particular socioeconomic characteristics, access to healthcare, lifestyle issues, attitudes and beliefs toward OPC, and preventative medicine should inform and shape interventions targeted to this population.

One of the strengths of this study is that the NYSCR and SEER program data sources are comparable. However, because of the limitations of the data sources we do not describe the potential effects of racial differences among Hispanics. Furthermore, the methods used by both the NYSCR and SEER to code Hispanic ethnicity may result in some misclassification. A study of the San Francisco Greater Bay Area cancer cases classified as Hispanics in SEER showed an underestimation of Hispanic cancer cases and incidence rates when compared with a classification based upon on self-reported ethnicity.²¹

Further comparative studies are needed to elucidate the behavioral, cultural, genetic, or familial risk factors that may influence the risk of OPC among Hispanics. Moreover, an enhanced health data collection system could yield more specific information about incidence and mortality rates among all the major ethnic subgroups in the United States. By avoiding, whenever possible, overly broad classifications of race and ethnicity, more specific and potentially more effective health promotion programs could be developed.

	Acknowledgments

 
This study was supported by the National Institute of Dental and Craniofacial Research, National Institutes of Health (grants U54 DE 14 257 and R21-DE 14425).

Human Participation Protection
No protocol approval was needed, because all data are unidentified and were publicly released by the SEER program and the New York Cancer Registry.

	Footnotes

 
Peer Reviewed

Contributors
G. D. Cruz led the study design, analyses, and writing. C. R. Salazar assisted with the study design, conducted the analyses, and prepared all tables and figures. D. E. Morse assisted with the study design and provided critical review of all aspects of data management. All the authors interpreted findings and reviewed drafts of the article.

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This Article Abstract Figures Only Full Text (PDF) All Versions of this Article: AJPH.2005.079137v1 96/12/2194    most recent Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Web of Science (3) Citing Articles via Google Scholar Google Scholar Articles by Cruz, G. D. Articles by Morse, D. E. Search for Related Content PubMed PubMed Citation Articles by Cruz, G. D. Articles by Morse, D. E.