Cancer in minority ethnic populations. R S Bhopal & J Rankin. S23. Table II Cancer in adult South Asian males: examples of an overview for needs assessment.
British Journal of Cancer (1996) 74, Suppl. XXIX, S22-S32 © 1996 Stockton Press All rights reserved 0007-0920/96 $12.00
Cancer in minority ethnic populations: priorities from epidemiological data R S Bhopala &J Rankinb Professor of Epidemiology and Public Healtha & Research Associate,b Department of Epidemiology and Public Health, School of Health Care Sciences, University of Newcastle
Abstract The aim of this paper is to review the literature on the frequency of cancers to develop priorities for cancer policy, prevention, services and research for black and minority ethnic populations in Britain. Data on populations originating in the Indian sub-continent, and Caribbean and African Commonwealth were extracted from published works. Cancers were ranked (top seven) on the basis of the number of cases, actual frequency, and also on relative frequency (SMR, SRR, PMR). Cancer was found to be a common cause of death. For example, during 1979-83 the proportion of deaths resulting from neoplasms in immigrants living in England and Wales was 11% for Indian and African men aged 20-49, and 19% for Caribbeans. The corresponding proportions were higher among women. The pattern of cancer depended on the method used to assess rankings. On the basis of the number of cases the top 3 ranking cancers for adults were breast, lung and neoplasms of the lymphatic system. Based on SMR's cancer of the gallbladder, liver and oral cavity ranked amongst the top 3 for adults. For children the top ranking cancers were acute lymphoblastic leukaemia, central nervous system tumours and neuroblastoma. Variations by ethnic group were more evident in the rankings of relative frequency than in rankings based on numbers of cases. In conclusion, the most common and preventable cancers among minority ethnic populations were the same as those for the general population. The different cancer pattern based on SMRs highlight additional needs and provide potential models for research into understanding the causes of these cancers. Health services policy and practice should ensure that the common and preventable cancers take priority over rare cancers and those for which there is no effective treatment or prevention. Priorities for policy, prevention, clinical care and research should be set separately, for they differ.
Introduction Making choices between alternative actions, priority setting, is all-important, particularly when resources are insufficient to meet identified needs and demands, as in health care. Setting priorities for minority ethnic populations is an exacting challenge for they are extremely heterogeneous and their disease patterns and lifestyles are incompletely understood, and are changing rapidly within and between generations. Recently, Bhopal has argued for a strategic approach to setting priorities for the health and health care of minority ethnic groups and has offered a set of guiding principles including: focusing on a few priorities; being guided by priorities identified by and for the general population; and emphasis on basic needs irrespective of similarities and differences between minority ethnic groups.1 Epidemiological data on disease frequency, causal and risk factors, and the population's characteristics can play a key role in identifying needs and setting priorities. This paper reviews published epidemiological data on the Table I Overview of studies included in analysis of priorities Authors Ref No. & Populations included in this gager Publication Date Adults born in Indian subcontinent and Marmot et al2 Caribbean and African Commonwealth 1984 Donaldson &
Clayton3 1984 1990 Balarajan & Bulusu5 1990
Adults identified as Asian by name
2. Which cancers deserve special attention in terms of policy, prevention, service provision, aetiological research and health services research. While the limitations of the published data mean that these questions can only be answered for a few of the minority ethnic groups in the UK, the principles of the approach outlined here, and possibly some of the conclusions, ought to be generalisable.
Terminology There is no agreement on appropriate terms for the scientific study of health by ethnicity. We have followed general conventions used in the UK and, whenever possible, the terminology used by the original authors. For example, the term
Type of cancer data
1976-1982 Leicestershire Health District
Cancer registration
251
Mortality statistics
3467 Indian S.C.
Mortality statistics
152
Metropolitan District
1979-1983 England and
Caribbean and African Commonwealth
Wales
Study Group database
Health Authority region
African
1129 Africa
Wales ethnic origin
African
1610 Caribbean
482
1992 1994
Total no. of cases in ethnic minority groups 1378 Indian S.C. Caribbean 578
Time and place data relate to 1970-78 England and Wales
Adults born in Indian subcontinent, and
1992 1991
frequency of cancer in UK minority ethnic populations to answer two key questions: 1 How common is cancer in these populations?; and
Children's tumour research group records
63
W. Indians
Cancer in minority ethnic populations R S Bhopal & J Rankin
Table II Cancer in adult South Asian males: examples of an overview for needs assessment Author, Ref No & Date of Study Total cancer cases Cancer as % of all (Overall SMR or SRR) mortality or morbidity A. Mortality 722 (SMR = 69) 16.6% Marmot et a12 (1984)
Balarajan & Bulusu5 (1990) * 20-69
*
70 +
B. Cancer Registration & Clayton3 (1984) Barker & Baker4 (1990)
*Donaldson
1,183 (SMR = 59) 646 (SMR = 65)
S23 Top 7 cancers % of all cancers
Top 7 cancers on SMR or SRR as % of all cancers
69
30
68
32
15.6%
15.9%
74
33
251 (SRR not stated)
Unknown
53
14
100 (SRR = 54)
Unknown
51
14
Male and female data combined by authors.
minority ethnic group refers, effectively, to a small number of minority populations not of European origin and characterised by their non-white status. The term South Asian is preferred here to Asian to refer to populations originating from countries in the Indian sub-continent. The term Caribbean, West Indian and AfroCaribbean usually refer to people born or originating in parts of the Caribbean previously in the British Commonwealth.
Similarly, the terms African, East African, West African refer to people born or originating in countries which were in the British Commonwealth. Sources of data and methods Published studiestudle were identified Publlhed wer ldetlfie uslg ange off methods mehods using a range including MEDLINE, follow-up of references and scrutiny of published reviews and bibliographies. From those papers and reports which provided information on cancer frequency in a defined population, and permitted analysis of cancer frequency for a range of causes, we extracted or calculated: * total cancer cases; * rankings of cancer (top seven) by frequency of occurrence; * overall standardised mortality ratio (SMR); and * rankings of cancer (top seven) by excess risk as indicated by the standardised mortality / cancer registration ratio (SMR/SRR) or the proportional mortality/registration ratio
(PMR/PRR).a Measures of relative frequency were converted to percentages where authors had reported data differently. The categorisation of cancers reported here is as given in the original reports, although very occasionally a decision has been made not to use sub-categories (e.g. overall retinoblastoma SMRs are used here, though the author did split cases into unilateral and bilateral retinoblastoma). Whenever possible, single cause rather than grouped causes were used eg leukaemia, rather than lymphoreticular tumours, and acute lymphoblastic leukaemia (ALL) rather than leukaemias. The studies which have been used2-9 are summarised in Table * The largest studies are based on mortality data, and focus on the Indian subcontinent born/origin (South Asian) and Caribbeanorigin populations, with some data on African-origin populations. There are major limitations of the data which make their interpretation and utilisation for priority setting awkward: 1. The studies by Marmot et al ,2 Balarajan and Bulusu 5 and Grulich6 are based on the country of birthz cod e on thne'death certificate. The country of birth does not accurately identify ethnic origin. For example many people of British origin were born and lived in Commonwealth countries and returned to Britain following the independence of their country of residence. Marmot et al have used a names analysis to _________________________________ a For definition of terms see introduction to the Epidemiology section
identify the South Asian group within the Indian subcontinent born population.2 2. Accurate denominators (population at risk) have not been available, making the calculation of accurate disease rates and standardised mortality ratio impossible, particularly between census years. The population at risk has been estimated usually from census data on country of birth, but also from the labour force
surveys.9 3. The assignment of ethnic origin has used various aroaches 3 h sineto tncoii a sdvrosaSoce eg names analysis for South Asian populations. " Two studies based ethnicity on information from medical records or asked doctors to assign it,8'9 and one study gave no information on how ethnicity was assigned In general the categories for ethnic categorisation were et al reported datanon East and West extremely broad. Africnsl, bu in. Grulich orsudice terewas Eretian of '
population by sub-region.
4. The numbers of cases in several studies were very low, particularly those based on regional, cancer registry data.3'4 79. The precision of the estimates of frequency is low in these studies and especially so for rarer cancers. 5. The study of Powell et al ,9 uses data also used in the studies by Muir (71% of cases), and by Stiller (20% of cases), which means that the three studies on children are not independent.
Findings i) Cancer as a health problem for minority ethnic populations Cancer was a common and important cause of death and
morbidity in the three ethnic groups reported on here causing about one-sixth of all deaths. Generally, cancer was less common in these ethnic groups than in the standard ("white") population, with the overall SMR mostly being in the range 50-80 for South Asian and Caribbean populations but about 100 in African populations (higher in West Africans and lower in East Africans). Table II illustrates, using data on South Asians, how published data can be used to provide an overview of the importance of cancer overall, and for top-ranking cancers. Clearly, a strategy focused on the commonest cancers captures a much higher proportion of all cancers (here 51-74%) than one focused on the cancers which are relatively common in relation to the standard population. This point is explored in the Tables.
ii.atrn.fcnerb
as
aAdlSotAsnpputis Two major studies based on mortality data, which permits country of birth analysis (and names analysis on South Asians), and two based on cancer registration where ethnic group was assigned by name provide a picture of the common, and relatively common cancers, as summarised in Table III (men) and Table IV (women), and for men and women together (Table V). Table III(Ai) shows that for men the seven commonest cancers
minority ethnic populations
Cancer in
$9
RS
Bhopal & J Rankin
S24
IV(A) for women, as for men, the seven commonest cancers, of which three were of the female
As shown in Table
accounted for about 70% of cancer deaths, and that leukaemia and lung (despite a low SMR, a dominating cause), stomach, prostate, pancreas and intestinal cancers were in the top ranks.
reproductive system, accounted for about 70% of cancers. Lung
ranking neoplasm, Those cancers which were relatively common in comparison to The pattern when those of South Asian origin were separated the population of England and Wales, including those of the liver (Table IV(Aii)) was a little changed, particularly with lung cancer and intrahepatic bile ducts, buccal cavity, gall-bladder, and from the second to sixth rank. The findings from the dropping larynx, accounted for a small proportion of the total cases. Table 1979-1983 study (Table IV(13)), and from the cancer registration III(Aii) confirms these fl'ndings for those of South Asian ethnic data (Table IV(Q and Table V) are concordant with the findings origin, but cancer of the buccal cavity and pharynx, and of of the data. The overall SMR for female the cancer was the second
liver reached both sets of
mortality
ranks.
top
and leukaemia third.
immigrants
The cancer registration data from Bradford (Table III(Q) are based on small numbers of cases, and those from Leicester (Table
from the Indian subcontinent was 90 in the study by Marmot et al and in that by Balarajan and Bulusu, 68 in the 20-69 age group, and 102 in the 70+ age group. The PMR was 46.2 The observation that while cancer of the liver and intrahepatic bile ducts was, on the basis of relative frequency, prominent in the mortality data but not in the cancer registration data is probably explained by its rarity and the fact that the latter data are based on small numbers of cases. Finally, it is worth noting that several of the cancers which ranked high on SMRs, tended to rank low on number of cases.
V) have the additional difficulty for interpretation of reporting on and women together, but the pattern was concordant with
Figures I a and I b (data taken from the Marmot et al study) illustrate graphically the main points above, in particular the
on data from the period 1979-1983, is largely in support of the pattem described above. The overall SMR for men born in the Indian subcontinent was 69 in the study by Marmot et al 2 and a little lower in that by Balarajan and Bulusu.5 For immigrants of 'Indian' ethnic origin, the proportional mortality ratio (PMR) calculated by Marmot et al was 46.
Table III(B), based
men
mortality data.
Table III Cancer experience of South Asian men: top seven based on actual and relative frequency
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:.:.:.:.:.:.:.:.:.:.:.:.:.:.:,:.: .... ''................... . . W". :,:,:,:"::,:,:,:,:B::,:,:,:,::-:-:-::.d*.-.---.-.-------.-----.-..::::.:::..:::;:::: i.. ,.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:,:.:.:.:.: "" 1-I. ::::: ::.:.:.:.:.:,:..:.:.:.:.:..:.:.::.:.::::;::: .'-.'...,-.,-.,-:-:- -.'-'.-'..-..'-.'-'.-..'-'.-'.-.'..,.."....:.:.:.:.:.:.:.:.,.,.:.:.:.:.:.: .... _.. ....P. :::::::--,..:..... ..................... .. :.. .......::::::::.. :!:::::::::::::: ..::, ,. ::::: ''&Y-1 :............... ........,.--:-:-X-X I`-'-"`:::::::::.............-".", -11I...... ......I-.... ..... .............................., ................ :::.:.:.:.:-:.:.:-:-:.:.:.:.:.:.:.:.:.:.:.:::::.:.,............................. ....... """' ..:.... .:::.. :.::::::" .."..-...';.. W. &::::::::::::::::::.:.:.:X... !:.:.:.,.-.,--.:..: ..... .'.... 11'... ..........X. -r--.... .: .............. .:. X.. ..., I..,.", .", ,::.:,:.: -.................,..''.."",.,.....,,:.X:::-:-:-:-X-:-: ............ ....................... X-X-X-:.: :::::::., ..:::., ...:.:.:.:-:-: -__ ...... ::::::: ..:.......................... ............'.'.......'...,..,.,.......&..'.":. .......'. .................,..l-................-,...............................-,-...,. .............. .:.:.:,:.:.................:.:.:.:.:.:.:.:.,.:.:.:.,-,
:: V:
....
,_.- . .1. -: : : :
P-
-.... r.I.I.I.I.I.........'.......'..... _1----,.......-_-..1-1.. ..-.-.........:,:.::.::.::.:,:.":,:.:.:.:.:.:.:.:.:.:.:.:...............-...:........
:A''li, ................
..:::::::% .........-I
.:!
._ .Y.i...".........'.." ...
-........
..:.:.:.:.:.:.:.:.:.:.:.:.:.:.:...
......................,...........
1268190
I 115336
-No of cases
Balarajan and Bulusu5 i) Age 20-69
-,
91
B
...;.;.;.....;..M.:.;.:.:.;.....;::.: ...,-:;:::::::::1 11'."i""i"", %::::: :::::.:.:. ."dF- : : ...... 0'1- i.!.i. -:,-: -:` In.c. -"""..S-tl"""""""""'."", .'."""""""""":"","","","""".'.I ,I"'h""""' ..-%.:. '-_M"id. .. -:`%-, C--.'-'-.D ..... I.1.. . .".Oes 'k'-"`-::b:::Ra_ftm...-i ::::::::::: 1. .Ni'l""""""""'],w.'.-""" ...... .........................O...:............P...;........ "..;..': . . . . . . ..MtaeBi.. - ..:.-.''::::::::::::::::::::.:.:.:.:.:,:.....:,."., .!. .i. ..,*.,:.. '' ,:...,:.:,.-,.-,:.,.:."..,::::.,::::::::.:::i:::::i::::i:i:i:,-.".i,::"""""". :: .,X.: ..;.;.;...;.:...:.;.
"':.-
"r"'e"'a""."'u'-""""",,
f
.;:.:;:.:...........".."........:.:.'.-.-.'.%-. .... ...... ....... -..... ::::. ...-.'.-.'...-.'.-.-.-.-................. :::::.... .,.:.:%.:.- """"""""""""""" .-,. ......:XX........... .... -.. :1 ::::: ........ ,.. .: .:: -," V.: ----':. :,::,-::::::::-" ;, ...... .........................%.... :- :,- -,: T"""" Im
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1.
.,.-.
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...- :.:.,.:.:.:.: ............................. ,.,. .":. : :.: : .:.:.:.:.: .: .: .:. . . -.`
.:
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::::::::::.:-:-:-:-X-X-::-:-:-:-:-... :: ......::::::.::::::: ::: I............. :::::::.:"",:::"::::::.,.%-%................................. ...: "': ': -.i......:ilil...].iii.i.i.iii.....i]i..::]..i.ii. :.:.X.:::::::::::::::::::: X: : : : : : : : : : ::,:.:.:,:.::.:.:.:.:.:.:.:.:.:.:.:.:.:,.:.,:,. :::::::::::::,.:::: ,*i-]*.'-,.`],j...: :::::::::,.::;.,.::::%,.,.,.,.,.,.,.,.,.,.'-'..........,.... :--iii".. ..:: -,:::::::::::;:::-,-,---, ': -::::::::::::::::::::::::;:::::::::::::::::::' %%%%`%-:::::,::::-::::: :::XN! ..:::::::::.,,....,... :-:-:-:-:-:::--.:,:-: .......... .: 1.!.-`----'1'," .....: '.-.%.......:::::::::::::::::::::::::::::::: -`.."-.!i :..:.: I-.i.i.;.i.i.i.!i.i.1,1: ::::.::::.:::::::::A::::::::::.:: .:. :: ::: :: :-:;x-:::::::::::::::::` :.......... e.."Y::,.:.:.:...:".:,:...:,:,:.::-:-:-:-:-:-:-::-::.... :::::::::::::::::::::::::,:: ,,:.-:,,:,,:":":.:.:.:.:.:.:.:.:.'.........' """""B"
:...
-.-.%-.-.-.-.-.-.-.. ........... ............I.............,... .-...-. -"........... ............, .... .%'.-.-.-.,.-.-...-.-....-..............-.-... ... ,.-. ...'...."
.m-
_:. __...........'.......
,,,,
I.... :::::::.:::::.:.:-::-:-:-:-:-:-:-:-:,:-::::::::::::::.::::;::,., '-'.-' ....-........... ......"... .:: .:... ::::;:::::::::::::::.::::::!:::::::::::::::::::::,.,.,.,.,.,.,.,.,.,.'-'-'-'-'-'-"'-'-.............'..":::..".,..,.."."".,.,.,.,.,.,.'.'."'", ..;...... .... ...'''...-,.:.:.:.: 1-1111.-:::"` ........... ........... ....... ..''..."'.1-1.1.1.1-1..L. :... ......."....,.....,................. -.,.,.....,...........t....., ..........a.:.:.:.:.:..."......,.,.,.,.,.,.,.,.,.,.,.,.,..,.,.,.,.,.,.,...,.,:::::::::.:::::::;::::::::::: ,.: :. .,.,.::,.::::::::::.:!:::.:::::::::::::::::::::::::::::::.: ..... ::.::.,::.::.:::.:::.::..:::::::::::::::;.,.''.,.....-..-...-.-.--.-.-.-..-.......:.:.:.:...;.:,:.:.:.:.:.:.:..... ................::;::::::::::::: :...,:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::..:::::::::::,:::::::::::::::::............,.,.": ,: : : : : : : ........................... : : : : : : : : : : : : . . : : : :-'-'-'-,.,.::":.::,::::::::::::::.::::::::%::::',, : : : : : :. :,: : : : : : :": : : ",. . .................... :,...... ..1.. ::::.-:::::v!::::: ..;............. :: '........%.
................. -....-.-.-..
-...
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.... . . . . ...
:::
:.:.::-:-X.-,-,..:.:.:.
..
...:;;
.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.::::::::::::::::::::...:
No of cases 346 153 78 SMR47 48 98
76645 1183 804 68 84 108(59) 56 64 'L.'-:-:-:-:-:-:-:-::-:-:&.i.i.i.i.i.;.i...i.i...i....---.O...."',"-..--1--':'...b "...L-."..'%"""""""""""ib"'W'.'C.'."""""',-",""",:,:,...,:....P...'A""K-I.I"I:.:,:,;,:,:,:,:,:, ...:.. ....... t.,:,:,:.,:,k:,i",;.".'d..--:-..4.,.W .... ,ag : M. : : :.!. V. r:.i. . .:. . . :. . . .i. .i. . . i.I ,.:W,:1;.j.':*,..,: -:.;,: ,` ---..--`_..'.." SO 'Oe .Ode. ", .........-. ','.-....... J-'--.'--:::::::::::::: '.'.-'.'..-::::: .".... -. ".-.-.::.:.:.:, '..1.-". ..-- '.-. -i'"... .-.;`"-.-.`-. .` -....`.-.'..4.N. . ..4.:...". . %. :. : ::... . "....'. '.I .-..-.."....--L..'.'.R.,r-,.,-Y.,..A..,":::: :.:,: .:.:.,:.:.::::..]:]:j:j:j;.:.:...:.:j:j:j:].. .i:::.,........................... :;. '- .-`.'.' :.:i.i,,: :.: :.i:. .".: :,.,.:,: : ": : i: . . -:. .....,.::,::,::,::,::,::,::,:.,::,::,::,::,::,::,::,::,::,::.::,::,::,:,:::.,.::: ... i.ii..i..iiii.ii.iiii..!!iiiiiii.ii!!;"...i:.:.iiiii.i......i....::::::;:::::::.:.:.:............... ........................ ....
"""I" .... -`::`-"-`-`.. ......... I........ ... .: -........Y.... I............................. ... I.I...
ii.":::"::::"'"',,B"""""""""""""'""'.
': O'IY.
I""'
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..............'.'...... .....,....
1.1-
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..............,.....................
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.....
.... .............. ....:::::::::::::::...:.%%......................... _........................... .......... ................................"........,............... ..._... ... :X ....:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.: .:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.: .. ::::,.: ....... .,.... ::::::::::::::: :::........................ ,:......-. ,:b :.:.,:.:.:.%.:.:.:.:........%%....%... `,ret :ft. X-X.:-:-:-:-:-:-:-:: .6c _.. i.:.::-.......%................... .I.I.I....,.........,.........,... "" """"""""""" ." ................W.. .......N-:-:,:-:-:-:-:-:-...:-, "."", """"""""",......., ::: ...",.L........,_ .11111:: ...................... :::: :.- ::::::::.;:::::::::,:.:i:.:.:.:.:.:.:.:.:j:j:.:j:.:.:.,.:.:.:...:.::. ::: -:-:-:-:-:.:-:-::-.-:-::: ..... I.::::::: .. :.,.,: .......................,,-... ,,:: ............ :::: :.::.""""h :::.:::.:::.%.,::.:.,-.:.: .i .: -:-:.:1:-:::t1: .:"..,"."r,',",",'..""",.,,.,,.,,.,,..,.,."""'. "":,.,..::.::.:...:.:::,::::.:.:.:,:.:.: ..j:..:..:..::..i.i.j:...:::i..,.,.i.'.., .." ', ::, ': .::::::::::::::::::::::::::::::::::::::::::: .,:: : : : : : .. ..::,..........,. . . . ;. . . . ,_ ....'' --......-. ... ;.M. :::.:-:-::-:-:-;-:,:-::::.:::::::::::::::::::::.,.:.:.:.:.:.: .,.,.... ... t-Ir .: .': .:.. .:- :.:: :::::::::::::::, ....'... :.:.:.:.:.:.:.:.:.:.:.:.:.:............,.. -.-,-,..-..-,-.-...%-.-.r.....::::::::::::::::::!:::::::::::::::::::::::::::.,.,.,.,.,....,.,., , .'.'-.-,..'-'.'.'-%'-............ :: ....... .:: ...................................% :::::,.::::::::::::::::::.:.::.:.:.:.:..:.:.:..:.:.:,:. ...... :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.: ::: ::::: :: ::.:'
'.,.. .-X.X-:.X--,-.-.
:..::::::.:.. ... .....:-.....:-.:!..:::...::-,::-.::..::-.-.-.-.-.-,-.-.-.-.,.I.e:- k: X: C.:::. W......y; .::...::.:::::::......................... :::::::::::::::::::.:.... ."I....... "''""'"""'..... ...........I..............:..,.-:j.,.,:.:j:.:j:j j:j: ::ii.i:i:..":i:i:.:]:.:.:,.,.,.:::...............-.-.j; '1'1,:::;:':`:,:::::: . . . . . . . . . .. ",..:.: : : :.:j:j:j:j:j:j:j--i.i.:.'.` :.:i:i:i.,. ,:i:i:i:i:i:i.".:.:. . .,.: :.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.: .:.:.:.:.', ........... .: : - :::::::::::::::::::::::::::::::::::::::::,:,:,.: -: : : : : .`.:.i.i. .:.O ..:]::: i.i.::;:::::: I-.,.,.::::..:...:.:.::::::::::::.::::::::::::::::::::::-..k.....,:::::::.$i. *,.,*,:
...........:.:.:.,.
-No of over 70 H) Age
cases 36
17
....
...... ,.,,.
.. ..-
I,- .......... ......... 11 ..
... '...,,-, .............. -,-,.,-,-,-
..........
7616 45153 .-
-......, -:-,7 4..............................."::::::::::::::::::::: :::::::..I.':':':.:':';'.':.:':.:':'::.:'::':::"""-" ;;::::::::::,:,:,;,:,:,:,:,:,:,:-..P...r.".,"""i..:::::",'':':':':':'.::::':L::':':':':':':""""h"""""""""""""""",:,:,;,.,;,S;",;,:,:,:,;,:,:,:,;,;.;,;,:.;.;.X.O.c....... .:::::: .. :---.)--..,-,.'-::.;: ... --:-:",`,-:,-':'-:`::.:.:.:.:.:.:.:.:.:.:.:.:::::::::.: ,:. -.':':.:: ::::.::::..:.:.:.:.:.:.:.:.:,:.:.:,............... "-.' .: : : : .: : ,:. :. ,:. : ;.:,:. . ._ ,- -.- . . -.-"..,:.:.:.:.:.: .:.:.:.:.:.:.:.: - -.",.'. .- -.-,.,.,. ,.l.'. .,.7.-i. .:.:.:.:.:.:.:.:.:.:.:][)I.M.,.:.:.:.:.:.:.:.:.:.:.: '' .:0.'A . . . . j,.. '.''. :: ....-:'X,:,:,:.:-:....-..... .:.:.:.:.:.:.:. -:: -...........:::::: :..................... ::......-...-.....-..-
"`a---`-=------------k------.---------. :-.:-:-:.:.:T:;:;:;:7:;:.:'-:.-'-:':':':,:,:,: :.
-:1111.1-1::
40
1.,,,, -I I,
7N
... ......."...... .......-........ _.....
,X
......,.....%.,....
Mo. i6:..... ....,-.. "I ....:.:.:.:.:.:.:.:.:.,.,.,.,.,.,.,.,.,.,.,.......... .'.-.*::i*::i*.,:................................ .*i.*,.,:.: .':::: ::::::::::::::::::::..:................%-.-.-.-.-... .. ....... ::::::::::::::::::::::.:.:.:,:.:.:.:.:.:,.:.:.: .......... .:::A ........... ..............XX.."... ...__ :::,-::::::::::::.-:.-, ::: ::::.. ,:::::::::. .,.:.:-: -.-.-.-.-. ......:::: :::::::::.:..-.-.-.-................. ,::::::::::::::::::: ::: .:.:.:.:-:-:-:.:-:-:::::.:.:..:::::::::: :.:.:.:.. .::.:.:.:.:.:.:.::::: .............. :.:.:i.,-...-...,....i.:...,--.--.-..-,i.,.--.i:.-'--..".ii."...,....... ::,-::::::!;::::: .:.,.,.,..,..,.. :...:.:...:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.: .. ....... -,-"""",""...................,.............. ...... ,:;:::,-:::::::,-.:.---:: :::::::-.::1.-... ..:. ........................ ........ ,:::::::::::::::::::::::::::::::::....:.:.:.', -:-:-X-:...... ............
.,-,-,.,.,-, --...........:::::::::!:::;:::::::::::::::::::::::::::::::::::::.:.:.:.:.:.:.:.:.:.:.:.:. I.:.!::: .::.::.: .'B--'_.....................-..:.:.:..:.. ..:.:.:.:.:.:.::.::.:.:::::::::::::,. :::,: !.-........,.,..........,-....,-,..-.......... ........... .'......................,......,.......,.....,....,....".......,.,......... -. . I. .
..,
48
Cancer in minority ethnic populations R S Bhopal & J Rankin S25
disparity in terms of cancer rankings when based on the number of cases and on SMRs.
and Bulusu5 (Table VI(B)). The overall SMR for Caribbean men was 79 in the study by Marmot et al,2 a figure comparable to that in the studies of Balarajan and Bulusu, and Grulich.6
b) Populations of Caribbean origin Table VI(A) shows that for men born in the Caribbean Commonwealth the commonest seven cancers, which include lung cancer, stomach cancer, and leukaemia, accounted for about 70% of cancers. In this group four of the cancers which were common, were also relatively common in comparison to the standard population i.e. stomach, leukaemia, prostate and liver cancer. This pattern was also found in the later study by Balarajan
For women, Table VII(A) shows that the seven commonest cancers contributed 67% of cancers, and the ranking was dominated by the reproductive tract (breast, cervix, ovary). The cancers ranking highest on SMRs were uncommon, but those of the lymphatic system, oesophagus, cervix and stomach appeared on both sets of rankings. The studies by Balarajan and Bulusu5 and by Grulich et at6 (Table VII(B and C)) gave similar findings.
qr-1.1- ill
----
.---- -,r C!-..fU A,,;-
t,,,,.,-A
+--
,-A
--
43
J/
FMviK
..
&lyrnphetic~~~~~~~~~~~~~~~~~~......
No of cases
.. ....
..
..............
....... .:.e..........
............... .......... ... ,... .. ..... ... ................. ........
......,,z,
....
S/
69
78
88
44
50
939
630
67
.e.,.........
9,...
..
49-
53 10
69 10
12
7
3
1
.1.......
69 ....................................
3~~~~%.
243
k4c)
lUU
J
DY1 Neoplasm ranked liver Oeaophagus~~~~~~~~~~ Stomach Leuluieinia....
PMR
0.)
1
(68)
No of cases ii) Age over 70
9
27
28
267
939
448
48
45 121
40 131
699 (102)
422
63
133 6
131 40
699
159
23
15
19
15
19
83 id.
. . '.
' ' ''"'"'""""""'""""'""''"''':''"""""''""""'""""""""'M"l'.. .
No of cases SMR .-
SMR No of cases
\ 3KK
...-
. ..""""'.. .'
...... .........."'
102 93
80 93
217
186
18
6
.....
..
......
70 87 162 12
1
1 4/
Necplasni GaIlTongue rankedby
I{ypo-.
.............
57 137
48 75
143 20
137
Jy
Y4
57
.......
..................
I1u
03
Placenta l..Bls............ Thyraid
~~~~~~~~~~~~~~~~~~~~~~~~~~~.........
Nervous
Mycloma..........
263 256 256 556 556 294 SRR 1000 3 2 2 1 1 3 No of.cases 3 an PltS frlle osa mz aXw/nvn TalandV over, ^nrronaane The smTall effects on theacXn row totals have been ignored fPlMP& here. not 20-69 years fQnih (latter data ca not reported by authors). roth-tn *20 years Donado v
aVInd_ ClaVton
Pk-al *3sF 1
al
V1sS
LVr,1-
.
3VJ
J_ v
abVJ
V
--a I
--- v_*
78
_
Donaldson and Clayton3
251
133
53
251
36
14
Cancer in minority ethnic populations R S Bhopal & J Rankin
250
* Trachea etc O Leukaemia E Stomach o Prostate 31 Intestine 0 Pancreas
200 150 0
o
160 140
-
100
50-
120 100
-
40,dl
.'80 60
T7Oesophagus
20
0 Figure la
Top 7 cancers in South Asian men based on the number of cases and SMRs
160
* Breast 4 Trachea etc 4 Leukaemia o Intestine X Ovary o Cervix
140 120
el00
° 14
80 --
Z
60140
R
Stomach
200
Figure lb
Top 7 cancers in South Asian women based on the number of cases and SMRs
Table VI
Cancer experience of Caribbean origin men: top seven based on actual and relative frequency
A Marmot et al 2 (aged 20 years + )
.
_-
I_-
SMK
37~Ps
Livertv
Nepamrankd
191
frequency......
69
71
316
154
49
744 (65)
538
72
744
370
50
119
78
153
94
61
Colon.
P...s..t.
9~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.........
36.
223
1V
(78)
42 1106
Lymphatic.Gallbladder
reatv 18....
316
-
.
.
19..9
C Grulich et a16
No ofcases SRR
0ii)Neoplsr SRR No ofcases
rake
473 40 Lie
339 110 Naso-pharyox
201 170 Mutil
189 50 Protat
153 100 Nba
131 90 Peals
117 160 Leukee
2388 (71)
1603
67
530 114
310 19
220 80
170 201
117
160
150 9
110 114
2388
654
27
Cancer in minority ethnic populations R S Bhopal & J Rankin
Cancer experience of Caribbean origin women: top seven based on actual and relative frequency
Table VII
A Marmot et al 2 (aged 20 years +)
Iv
969 /U Iu1 76
67 u/
(86)
1141)
SMR
78
143
112
32
49
106
40
£NAP
9qQ
1AR
119
lOll
1O(
109
OR
NO or cases
92
70 -_
* Trachea etc Z Stomach O Leukaemia o Prostate LI Intestine O Liver
60 C
50
-
0
0
40
0
Z30 20
r
10
Pancreas
0
Figure 2a
50 (A
40
o 30
0
20 10 (1 v
1000 900 800 700
600 500 400 300 200 100 0
I 4A\ lU
60
z
46
Top 7 cancers in Caribbean origin men based on the number of cases and SMRs
lv
u
38
--
Figure 2b
H
* Breast 6 Leukaemia W Cervix o Stomach " Intestine 0 Trachea etc M Ovary
140 120 100
9 80 60 40 20 Av
Top 7 cancers in Caribbean origin women based on the number of cases and SMRs
4
68
AA
192
33
(71) 590
V
1 14
I 4Y
%J VV
VJ
123
47
38
1890 (76)
1278
68
1890U 287
1l
Cancer in minority ethnic populations R S Bhopal & J Rankin
S28 The overall SMR in the study by Marmot et a12 was 86, a figure a little higher than those given by Balarajan and Bulusu, and Grulich et al.
c) Populations ofAfrican origin Table VIII(A) shows that the seven commonest cancers in African-born men, led by lung, leukaemia, and stomach, accounted for 66% of all cancers. Cancers of the liver, pancreas, stomach and of the prostate were shown to be both common and relatively common, appearing in both sets of rankings. The overall SMR was 102.
The main differences in cancer rankings to emerge when the number of cases are compared with SMRs for Caribbean origin populations are shown in Figures 2a and 2b.
Table VIII
Cancer experience of African origin men: top seven based on actual and relative frequency
SMR
93
42 i)
ra..........
Liiei&
..
SMR No ofcases
977 6
66
249
303
116
977
97 (102)
64
117
249 9
186 4
184 1
142 1
117 10
97
39
40
219 (71)
138
63
219
107
49
43 (70)
36
84
4'+
J0
o'4
343 (138)
230
67
343
127
37
326
212
65
I Z.)
dl/
.?
303 8
R Rxlnrrrisn snnf R111111C115
iNo or cases C Grulich et al :6 West African 1) rns y asm ;1eAopi ..... .... ini
3
0 V.
I-.......
........
........:
..... ....... i... . w
,....................................
No of cases
SRR ........by ........ ii) Neopls ranked .............
SRR
.................
60 70
3160
:::.: :.:.:.:.:::.:.:.:::::.:....
::
................ s.
s
3160
100
25 120
40it 410
370
350
260
26
.''.2..'. 20
..
26 350
50
1
23 210
Qophs.
260
.....
250.........
210
(63)
INv VM buNcs
I
-
'Y
v
Trachea etc
12 Z Leukaemia
10 Stomach
CZ,
0 0
El Pancreas
6
Il
4
Q
z
2 0
Figure 3a
4
j/,
)
l(nn)
14
8
3.3
Prostate Intestine
~--Liver
900
-
800 700 600
-
-
S 500 400 300 200
-
100 0
-JENEEL.
u tm
Top 7 cancers in African origin men based on the number of cases and SMRs
---m
rF----l
r X] l|
Cancer in minority ethnic populations R S Bhopal & J Rankin
S29
The studies by Balarajan and Bulusu,S and by Grulich et al,6 supported the above analysis and provided additional patterns of interest. Balarajan and Bulusu showed that liver cancer was common in the 20-69 year age group, but not in those over 70 years (Table VIII(B). Grulich et al showed that liver cancer was only common in West Africans, not East Africans. In East Africans, cancer of the oral cavity was one of the prominent cancers. In the study by Grulich et al, the overall SMR for West Africans was 138, and for East Africans 63.
the reproductive tract, with breast cancer being top ranking, were common. The top ranking seven cancers were 62% of the total. Most of the cancers which ranked highest on SMRs were uncommon, but cancer of the pancreas was common in actual and relative terms. The study of Balarajan and Bulusu5 (Table IX(B)) confirmed the above picture and, in addition, showed cancers of the pharynx and oral cavity to be common. In this study, for women unlike for men, liver cancer was uncommon in those 2069, and there was only one case in the 70+ age group.
Table IX(A) shows that for African-born women the cancers of
Table IX Cancer experience of African origin women: top seven based on actual and relative frequency A Marmot et al 2 (aged 20 years +)
iNo or cases
9I
...,.,...... ......
,.oSLive.:.6W.0.:x
..
i..&...
i
. . .375 . . .3. 75.'
1 C Grulich et al :6 West African
62
I
0
Is JJ
01 IL I
JO2
195
134
69
(83)
2
26
10
91
53
*..]
L
14
S
109
34
55
JJ
(92)
14
No of cases
SMR
J
d.
re..........c...
f. :. . ..
6
1
195
59
30
25
17
68
76
375
(62)
25
15
60
Pancreas 60
119 (114)
80
67
11
4
119
27
23
341
224
66
81
24
........ ... ..
.....Pa ,,,,, . ..... ......
132
204
...., c. .
.
...
91 2
.................................
: :. ':'':'.". "':"........... ::.
..~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~........... g 0 0 0 Am 0 0!mES040 0 t0 0Si Sigigi g lig iG"g |00100 5 5 6
.frequency . . S. . . . . 0N
No ofcases ake y Nepas SRR SRRR
6 11 10 37 Orlcviy.asp..n.ivr..Olladl 120 160 180 130
Ueu 60 150 L.ukat.ia
.......7...
.......
No of cases
3
et at :6 East African Drelative Grulichfrequency
2
3
1
~~~
3
~ ~~~~~~~~~~~~~.......... .neli..p.rnxH..kd R0 0
No of cases SRR
102 90
32 130
25 60
19 50
18 50
14 1070
14 240
(80)
SRR No of cases
1070 14
240 14
180 4
170 5
160 1
130 32
110 11
341
14
14 12
12 10
10
