Department of Health and Human Services Department of Health and Human Services

Indian Health Service Indian Health Service

Division of Epidemiology and Disease Prevention Division of Epidemiology and Disease Prevention

CancerMortalityAmong

AmericanIndiansandAlaskaNatives:

RegionalDifferences,1999–2003
Suggested citation: 

Haverkamp D, Espey D, Paisano R, Cobb N. Cancer Mortality Among American Indians and Alaska Natives: Regional Differences, 1999–2003. Indian 

Health Service. Rockville, MD, February 2008. 

Available in Portable Document Format at: 

http://www.ihs.gov/medicalprograms/epi/index.cfm? 

module=health_issues&option=cancer&cat=sub_4 

Copyright information: 

All material in this report is in the public domain and may be reproduced or copied without permission. Citation to source, however, is appreciated. 

Note: 

The findings and conclusions in this report are those of the author(s) and do not 

necessarily represent the views of the Centers for Disease Control and Prevention or the Indian Health Service. 
 

 

 

 

 

 

 

 

Cancer Mortality Among
 

American Indians and Alaska Natives:
 

Regional Differences, 1999–2003
 

Donald Haverkamp, MPH*
 

David Espey, MD*
 

Roberta Paisano, MHSA†
 

Nathaniel Cobb, MD†
 

February, 2008 

*	 Division of Cancer Prevention and Control, National Center for Chronic Disease 

Prevention and Health Promotion, Centers for Disease Control and Prevention, 

assigned to the Indian Health Service, Division of Epidemiology and Disease 

Prevention. 

†	 Division of Epidemiology and Disease Prevention, Office of Public Health Support, Indian Health Service. 
_______________________________________________________________________ 

 

 

 

 

 

 

 

 

 

 

 

 

CONTENTS PAGE 

Purpose and Description of Cancer Mortality Among American Indians and Alaska Natives.................. 1 

Overview of the Indian Health Service ................................................................................. 1 

Indian Health Service Structure................................................................................. ......... 2 

Introduction........................................................................................................ ......... 3 

Methods and Sources of Data 

Denominator — IHS Service Population..................................................................... 4 

Numerator — Mortality Data.................................................................................. 6 

Change to Regional Analyses................................................................................. 7 

Analysis........................................................................................................... 7 

Results........................................................................................................................ 7 

Discussion.................................................................................................................. 8 

References......................................................................................................... ......... 10 

Tables and Figures for Regional Differences, 1999–2003 

CHSDA Counties Used in Cancer Mortality Analyses 

for the AI/AN Population by Region.......................................... Figure 1 .............................. 5 

Total U.S. All Races Population 2003 Population Pyramid .............. Figure 2 .............................. 6 

Total AI/AN Population 2003 Population Pyramid........................ Figure 3 .............................. 6 

Definition of geographic regions, corresponding IHS service 

population, total AI/AN population of states included in regions, 

and service population percentage for 1999–2003......................... Table 1 ............................... 13 

Cancer Site Groupings for ICD-10 Coded Mortality Data................ Table 2 ............................... 14 

Cancer Mortality Rate Ratios, AI/AN compared with U.S. All Races 

Both Sexes............................................................ Figure 4 .............................. 17 

Males.................................................................. Figure 5 .............................. 18 

Females............................................................... Figure 6 .............................. 18 

All Site Cancer Age-Adjusted Mortality Rates, 1999–2003 

Both Sexes............................................................ Figure 7 .............................. 19 

Total Number of Deaths and Age-Adjusted Rates............... Table 3 ............................... 19 

Males.................................................................. Figure 8 .............................. 20 

Females................................................................ Figure 9 .............................. 20 

Stomach Cancer Age-Adjusted Mortality Rates, 1999–2003 

Both Sexes............................................................ Figure 10 ............................. 21 

Total Number of Deaths and Age-Adjusted Rates............... Table 4 ................................ 21 

Males.................................................................. Figure 11 ............................. 22 

Females................................................................ Figure 12 ............................. 22 

Colon and Rectum Cancer Age-Adjusted Mortality Rates, 1999–2003 

Both Sexes............................................................ Figure 13 ............................. 23 

Total Number of Deaths and Age-Adjusted Rates.............. Table 5 ............................... 23 

Males.................................................................. Figure 14 ............................. 24 

Females................................................................ Figure 15 ............................. 24 

I 
Liver and Intrahepatic Duct Cancer Age-Adjusted Mortality Rates, 1999–2003
 

Both Sexes........................................................... Figure 16 ............................ 25
 

Total Number of Deaths and Age-Adjusted Rates............. Table 6 ............................... 25
 

Males................................................................. Figure 17 ............................ 26
 

Females............................................................... Figure 18 ............................ 26
 

Gallbladder Cancer Age-Adjusted Mortality Rates, 1999–2003
 

Both Sexes............................................................ Figure 19 ............................ 27
 

Total Number of Deaths and Age-Adjusted Rates.............. Table 7 ............................... 27
 

Males.................................................................. Figure 20 ............................ 28
 

Females............................................................... Figure 21 ............................ 28
 

Pancreas Cancer Age-Adjusted Mortality Rates, 1999–2003
 

Both Sexes............................................................ Figure 22 ............................ 29
 

Total Number of Deaths and Age-Adjusted Rates.............. Table 8 ............................... 29
 

Males.................................................................. Figure 23 ............................. 30
 

Females............................................................... Figure 24 ............................. 30
 

Lung Cancer Age-Adjusted Mortality Rates, 1999–2003
 

Both Sexes............................................................ Figure 25 ............................. 31
 

Total Number of Deaths and Age-Adjusted Rates............... Table 9 ................................ 31
 

Males.................................................................. Figure 26 .............................. 32
 

Females................................................................ Figure 27 .............................. 32
 

Breast Cancer Age-Adjusted Mortality Rates, 1999–2003
 

Females................................................................ Figure 28 .............................. 33
 

Total Number of Deaths and Age-Adjusted Rates............... Table 10 ............................... 33
 

Cervical Cancer Age-Adjusted Mortality Rates, 1999–2003
 

Females................................................................ Figure 29 .............................. 34
 

Total Number of Deaths and Age-Adjusted Rates............... Table 11 ............................... 34
 

Ovary Cancer Age-Adjusted Mortality Rates, 1999–2003
 

Females................................................................ Figure 30 .............................. 35
 

Total Number of Deaths and Age-Adjusted Rates............... Table 12 ............................... 35
 

Prostate Cancer Age-Adjusted Mortality Rates, 1999–2003
 

Males................................................................... Figure 31 .............................. 36
 

Total Number of Deaths and Age-Adjusted Rates............... Table 13 ............................... 36
 

Kidney and Renal Pelvis Cancer Age-Adjusted Mortality Rates, 1999–2003
 

Both Sexes............................................................ Figure 32 .............................. 37
 

Total Number of Deaths and Age-Adjusted Rates............... Table 14 ............................... 37
 

Males.................................................................. Figure 33 .............................. 38
 

Females................................................................ Figure 34 .............................. 38
 

Miscellaneous Malignant Age-Adjusted Cancer Mortality Rates, 1999–2003
 

Both Sexes............................................................ Figure 35 .............................. 39
 

Total Number of Deaths and Age-Adjusted Rates............... Table 15 .............................. 39
 

Males.................................................................. Figure 36 .............................. 40
 

Females................................................................ Figure 37 .............................. 40
 

Five Leading Causes of Cancer Mortality, 1999–2003, by Geographic Region and Sex
 

By Average Annual Age-Adjusted Rates......................... Table 16 ............................... 41
 

II 

_______________________________________________________________________ 

CONTENTS PAGE
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Purpose and Description of Cancer Mortality Among American Indians and Alaska Natives: Regional Differences, 1999–2003 

This monograph reports regional cancer mortality rates among American Indians and 

Alaska Natives (AI/ANs) within areas served by the U.S. Department of Health and Human Services (DHHS), Indian Health Service (IHS). These areas are comprised of certain counties found within 35 states. AI/ANs residing in these counties represent about 

56% of the total AI/AN bridged single-race population in the United States. We present 

the cancer mortality rates for 1999–2003 for the principal cancer types and compare 

them with the general U.S. population rates during the same period. We also present 

the estimated IHS service population for each region. The purpose of this publication is 

to provide detailed information on the impact of cancer among AI/ANs, with a focus on 

the regional variability of cancer mortality for this population. 

This publication was made possible by the partnership between the IHS Division of 

Epidemiology and Disease Prevention and the Centers for Disease Control and Prevention (CDC) Division of Cancer Prevention and Control, utilizing resources available 

from the National Cancer Institute, National Institutes of Health, and CDC’s National 

Center for Health Statistics. 

Overview of the Indian Health Service 

IHS is responsible for providing health services to members of federally recognized AI/ 

AN tribes on the basis of laws passed by the U.S. Congress pursuant to its authority to 

regulate commerce with the Indian nations as explicitly specified in the U.S. Constitution and in other pertinent authorities. On August 5, 1954, the Indian health program 

became a primary responsibility of the U.S. Public Health Service (USPHS) under the 

Transfer Act (Public Law 83-568). This act provides that all functions, responsibilities, 

authorities, and duties relating to the maintenance and operation of the hospital and 

health facilities for AI/ANs and the conservation of Indian health shall be administered 

by the Surgeon General of USPHS.1 

The IHS mission, in partnership with AI/AN people, is to raise their physical, mental, 

social, and spiritual health to the highest level possible. The IHS goal is to ensure that 

comprehensive, culturally acceptable personal and public health services are available 

and accessible to all AI/AN people. To carry out this goal, IHS acts as the principal federal health advocate for Indian people.2 

IHS has implemented its responsibility by developing and operating a health service 

delivery system designed to provide a broad-spectrum program of preventive, curative, 

rehabilitative, and environmental services. This system integrates health services delivered directly through IHS facilities and staff with those purchased by IHS through contractual arrangements, taking into account other health resources to which AI/ANs 

have access. Tribes are also actively involved in program implementation. 

1 
Two key laws enacted to improve the health status of AI/ANs are described as follows: 

•	 The 1975 Indian Self-Determination and Education Assistance Act, Public Law 

93-638, as amended, builds on IHS programs in their communities and provides 

funding for improvement of tribal capability to contract under the act.3 Under this 

act, tribes can chose to continue to receive health services provided directly by 

IHS or they can opt to take control of their own health-care services by managing IHS funding directly. They can also selectively manage certain components 

of their health services and leave others to IHS. Approximately half of the IHS 

budget is transferred directly to tribes under self-governance arrangements, and 

more tribes are expected to do so in the future. As these tribes move to selfgovernance for health services, they are going to rely increasingly on regional 

health profiles to guide them in strategic planning for optimal use of these resources. 

•	 The 1976 Indian Health Care Improvement Act, Public Law 94-437, as 

amended, was intended to elevate the health status of AI/ANs to a level equal to 

that of the general population through a program of authorized higher resource 

levels in the IHS budget.4 Appropriated resources were used to expand health 

services, build and renovate medical facilities, and set up the construction of 

safe drinking water and sanitary disposal facilities. It also established programs 

designed to increase the number of AI/AN health professionals and to improve 

health-care access for AI/AN people living in urban areas. 

Indian Health Service Structure 

The IHS health services delivery system is managed through local administrative units. 

A service unit is the basic health organization for a geographic area served by IHS, just 

as a county or city health department is the basic health organization in a state health 

department. These are defined areas, usually centered around a single federal reservation within the continental United States, or a population concentration in Alaska. A 

limited number of service units cover multiple small reservations; certain large reservations are divided into multiple service units. All of IHS service units are grouped into the 

following 12 larger cultural-demographic management jurisdictions known as IHS Area 

offices:5 

Aberdeen Billings Oklahoma 

Alaska California Phoenix 

Albuquerque Nashville Portland 

Bemidji Navajo Tucson 

As of January 2007, the Area offices consisted of 164 IHS and tribally managed service units. IHS operated 33 hospitals, 52 health centers, 38 health stations, and two 

school health centers. AI tribes and AN corporations operated 15 hospitals, 220 health 

centers, 116 health stations, 162 Alaska village clinics, and nine school health centers.6 

2 
Cancer Mortality Among AI/ANs: Regional Differences, 

1999–2003 

INTRODUCTION 

IHS has strived to improve the health of AI/ANs in the United States for >50 years. The 

results have been marked decreases in infectious disease mortality and infant and maternal mortality. Since 1973, life expectancy at birth for AI/ANs nationally has increased 

by >9 years and is now at 74.5 years. However, this is still approximately 2.4 years 

less than that for the U.S. general population.7 With these improvements in health 

status and increased life span, chronic diseases have begun to impact heavily on the 

AI/AN community. Malignant neoplasms are the second leading cause of death for AI/ 

ANs throughout the country.8 In Alaska, cancer is the leading cause of death among 

ANs.9 Although the majority of detailed cancer surveillance, including cancer mortality, 

has focused on AI/AN populations in the Southwest and Alaska 10-18, selected authors 

have examined cancer trends nationally.19-23 

In 1997, Cobb and Paisano examined cancer mortality trends for 1989–1993 for AI/AN 

populations residing in counties on or near Indian reservations.24 They reported that 

the AI/AN population had overall lower cancer mortality when examined nationally, yet 

displayed marked regional variation when examined at the IHS Area level. Garguillo et 

al. reported trends in mortality for four major cancers (lung/bronchus, colorectal, prostate, and breast) by sex and race/ethnicity for 1990–1998. They determined that cancer mortality among AI/AN either increased for a given cancer and sex while decreasing in other major racial/ethnic groups (most common), or AI/AN experienced proportionally greater increases or proportionally smaller decreases in cancer mortality 

(prostate).22 Because they did not attempt to adjust for the known racial misclassification for AI/ANs in state vital records, the rates are probably underestimates. Consequently, the disparities would likely be greater if racial misclassification were accounted 

for. 25, 26 Espey et al. compared 1990–1995 with 1996–2001 data and determined that 

there was an increase in cancer mortality during the latter period for AI/ANs, whereas 

cancer mortality had decreased in the United States for all races combined.21 

Initial IHS cancer mortality monographs 24, 27 reported cancer mortality data for the 12 

IHS administrative Areas (IHS Areas).5 The tables and charts in the most recent IHS 

cancer mortality monograph depicted broader geographic regions instead of IHS Areas.20 In this monograph, mortality rates are again reported by geographic region, with 

the addition of a sixth region (Southern Plains). 

These studies and publications revealed certain key points. First, U.S. AI/AN mortality 

rates differ substantially from U.S. rates for all races combined. Second, marked regional differences exist in rates of cancer mortality and incidence among AI/ANs in the 

United States. Third, recent trends in AI/AN cancer mortality are substantially different 

and typically less favorable, compared with other major racial/ethnic groups. Most of 

these studies used different methodologies and different study periods, making comparisons difficult. This report provides data regarding cancer mortality among AI/ANs 

3 
 

and, by using similar methods, allows comparison with data collected during previous 

periods. 

METHODS AND SOURCES OF DATA 

Denominators — IHS Service Population and United States All-races Population 

All mortality rates and population estimates for this monograph were calculated using 

SEER*Stat (Surveillance Epidemiology and End Results), Version 6.3.5 (available at 

http://seer.cancer.gov/seerstat/).28 CDC's National Center for Health Statistics (NCHS) 

provides the underlying mortality data for SEER*Stat databases. The IHS service 

population counts used in this monograph are based on U.S. Census Bureau intercensal county population estimates, updated in February 2006, after adjustments based 

on the 2000 census were made under an interagency agreement between the National 

Institutes of Health (NIH)/National Cancer Institute (NCI) and the U.S. Census Bureau. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

During the decennial census, the U.S. Census Bureau enumerates those persons who 

identify themselves as AI/AN. The intercensal estimates are developed by using a cohort-component method whereby each component of population change — births, 

deaths, domestic migration, and international migration — is estimated separately for 

each birth cohort by sex, race, and Hispanic origin.29 The IHS service population is estimated by including only AI/ANs who reside in counties in which IHS has clinical facilities or that are in or adjacent to federally recognized Indian lands (IHS service areas). 

These counties are referred to by IHS as contract health service delivery areas 

(CHSDA). The IHS service population refers to the AI/AN population residing in 

CHSDA counties — regardless if they use IHS services. 

County-level population estimates from the U.S. Census Bureau that were modified by 

NCI were used as denominators in the rate calculations.30 The 2000 census allowed 

respondents to identify themselves as multiracial. Because of this, NCHS and the U.S. 

Census Bureau developed bridging methods for single-race estimates to describe 

long-term trends in disease.31 This bridging method has a substantial impact on AI/AN 

bridged population counts. For the United States as a whole, the bridged AI/AN population count is 12.0% higher than the single-race count. 

During 1999–2003, the average annual IHS service population was 1,694,439 persons, whereas the average for the entire AI/AN bridged single-race population in the 

United States was estimated at 3,007,510 persons (Table 1, columns 2 and 3). Of the 

six regions chosen for this monograph, the Southwest region has the largest IHS service population (approximately 520,437 persons), distributed in five states and including four IHS Areas (Figure 1). Next is the Pacific Coast region (369,217 persons), representing five states and two IHS Areas. The Southern Plains region, representing 

three states and two IHS Areas, has 327,262 persons. The Northern Plains region, 

representing 11 states and three IHS Areas, has 265,912 persons. Alaska (108,462 

persons) represents one state and one IHS Area, and the East region, representing 25 

states and Washington, DC, and one IHS Area, has 103,149 persons. This distribution 

is represented in Table 1. Of note is that the population included in these regions does 

not reflect the concentration of AI/ANs in the United States. Rather, it is becoming a 

4 
standard method for analyzing and presenting AI/AN-specific data (see Change to Regional Analyses on page 7 of this monograph). There are several precedents for using 

regional analyses when analyzing AI/AN populations data.19-23, 32, 33 

To remain consistent with past versions of the monograph, the United States all-race 

population rate was used as a reference group for comparison to the regional AI/AN 

rates. This reference group included all race/ethnic groups, including AI/AN, and included all fifty states and Washington, D.C. Although not presented in this report, the 

authors also compared regional AI/AN rates to rates among Non-Hispanic whites. Tables showing these comparisons can be found at the IHS Division of Epidemiology and 

Disease Prevention website (http://www.ihs.gov/medicalprograms/epi/index.cfm? 

module=health_issues&option=cancer&cat=sub_4). Not all states in the United States 

contain IHS service areas. In the 35 states that do, only a subset of counties are service/CHSDA counties. Figure 1 displays the states and CHSDA counties within each of 

the six regions used in this analysis. On the basis of the intercensal population estimates, approximately 56% of all AI/ANs in the United States reside within the geographic boundaries of the IHS service areas. 

Figure 1. CHSDA Counties Used in Cancer Mortality Analyses for the 

AI/AN Population by Region 

 

Northern Plains
 

Alaska
 

Pacific 

Coast 

East Southwest 

State 

Southern Plains 

CHSDA* County 

*Contract Health Service Delivery Areas (Only data from CHSDA counties included for AI/AN analyses) 

5 
Numerator — Mortality Data 

AI/AN vital event statistics are derived from data furnished by NCHS, who obtains birth 

and death records for all U.S. residents from the state health departments, on the basis of information reported on official state birth and death certificates. The records received from NCHS by IHS do not contain names, addresses, tribal identity, or medical 

record identification numbers. Each record includes the single underlying cause of 

death and is determined according to standard criteria and data listed on the death 

certificate. The records also contain county of residence, which allows selection of 

deaths of residents in counties located within IHS service areas. These investigators 

examined only those AI/AN deaths for 1999–2003 in which the underlying cause of 

death was cancer, as determined by International Classification of Diseases, 10th Revision (ICD-10) codes in the range of C00–C97 (Table 2). 

The AI/AN vital events data in this publication pertain only to those AI/ANs residing at 

the time of their death in the counties that constitute the IHS service areas. By limiting 

the analysis to the AI/AN populations of IHS service counties where more awareness 

of AI/AN racial/ethnic identity exists, racial misclassification is minimized.34 

Because the AI/AN population is considerably younger than the U.S. all races population (Figures 2 and 3), and for reasons of comparability with recent analyses and publications, mortality rates presented in this report have been age-adjusted by the direct 

method, using the 2000 U.S. population as the age standard. An adjusted rate that 

was computed on the basis of a limited number of deaths should be interpreted with 

caution, because the adjusted rate might differ from the underlying rate. Cell suppressions were not applied in the case of small numbers, due to the desire of AI/AN populations to present these data, which have typically been suppressed in the past. 

 

 

US All Races Population 2003 

80-84 

70-74 

60-64 

15 10 5 0 5 10 15 

Age G roups 50-54 

Female 

40-44 Male 

30-34 

20-24 

10-14 

00-04 

Percentage of total population 

Figure 2 

 

 

Total AI/AN Population 2003 

15 10 5 0 5 10 15 

00-04 

10-14 

20-24 

30-34 

40-44 

50-54 

60-64 

70-74 

80-84 

A ge g rou p s 

Percentage of total population 

Female 

Male 

Figure 3 

6 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Change to Regional Analyses 

The first two monographs presenting cancer mortality data for AI/AN used the IHS areas as the geographic unit of analysis.24, 27 Although convenient and of interest for programmatic purposes, this approach posed problems. First, certain area rates were not 

stable because of a relatively limited number of cases. Second, certain counties were 

split between two or more IHS Areas; therefore, cases were arbitrarily assigned to one 

IHS Area or the other on the basis of their percentage coverage of that county. Lastly, 

use of IHS Area boundaries could imply tribal affiliation, to which tribal leaders and 

members might object. Despite the breakout of rates by IHS Area, the distinct patterns 

were often more regionally specific than IHS Area-specific. On the basis of these considerations, the ensuing monograph used broader regions of the country as the geographic unit of analysis, as opposed to IHS administrative areas. As in the previous reports, the analysis was restricted to CHSDA/service counties to mitigate the effects of 

misclassification. Since then an additional region has been proposed and this monograph includes this new region in calculating cancer mortality rates among AI/ANs. The 

new “Southern Plains” region was proposed as a result of feedback from several tribes 

in both eastern and southern plains states, stating that the cancer mortality rates of the 

original “East” region were not representative of the rates that they saw among their 

own populations. This regional approach addresses certain limitations of the IHS Area 

analysis and offers more stable rates on which to base programmatic decisions. It also 

offers a more standard approach by using state and county boundaries that are more 

consistent with census data and with analyses used by other entities. An additional 

method used to control for fluctuation in rates that occur when a relatively limited population and number of deaths exist is the aggregation of data throughout a 5-year period. 

Analysis 

Data were examined for all cancer deaths combined as well as for leading cancer sites 

and sites. Average annual age-adjusted mortality rates were calculated by using the 

estimated 1999–2003 population for each Region (Table 1, column 2). To compute 

95% confidence intervals (CIs) for each rate, we used the method described by Fay 

and Feuer.35 We also calculated mortality rate ratios (MRRs) and 95% CIs, using the 

Breslow and Day method, to compare the relative difference in age-adjusted mortality 

rates with the U.S. general (USG) population for the same period.36 

RESULTS 

During 1999–2003, the average annual age-adjusted cancer mortality rate among AI/ 

AN for all cancers for both sexes combined was 161.9/100,000 population for all regions combined. This rate was significantly lower than the rate for U.S. all races of 

195.7/100,000 population (MRR, 0.83; CI, 0.81–0.85). Males had greater cancer mortality (191.2/100,000 population) than females (141.9/100,000 population), but both 

groups had significantly lower mortality when compared with the USG population 

(MRR, 0.78; CI 0.76–0.81 for males and MRR, 0.86; CI 0.84–0.89 for females). 

7 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marked variation occurred among regions; the Southwest, East, Pacific Coast, and 

Southern Plains all had rates below the USG population (MRRs, 0.67, 0.71, 0.72 and 

0.79, respectively). Alaska and the Northern Plains had higher rates (MRR, 1.24 and 

1.30, respectively) for all cancers, both sexes combined. For all regions combined, 

MRRs for 12 leading causes of cancer death are illustrated in Figures 4–6. Tables of 

MMRs for specific cancer sites (by sex and region) are accessible at the IHS Division 

of Epidemiology and Disease Prevention website (http://www.ihs.gov/ 

medicalprograms/epi/index.cfm?module=health_issues&option=cancer&cat=sub_4). 

Lung cancer was the leading cause of cancer mortality in the United States as well as 

for the IHS service population overall (Table 16). Among AI/AN populations, for all regions combined, lung cancer was followed by colorectal cancer, miscellaneous malignant cancer, and breast and prostate cancers. Lung cancer was the leading cause of 

cancer death in all regions except the Southwest, where the leading category of cancer 

death for female and both sexes combined was miscellaneous malignant cancer. 

When we examined cancer mortality rates by specific cancer site and by sex, substantial variations among the regions were evident. Detailed results for 12 cancer sites are 

displayed in Figures 7–37 and Tables 3–15. For each region, the five leading causes 

of cancer mortality are listed in Table 16. 

DISCUSSION 

The data presented here demonstrate that the cancer mortality burden among AI/ANs 

throughout the United States is different from that of the USG population. In general, 

AI/ANs in the Southwest, East, Southern Plains, and Pacific Coast regions had lower 

cancer mortality rates than those in the northern part of the country. However, within 

any geographic region, mortality rates for specific cancers were not all lower or higher 

than the U.S. rates. For each specific type of cancer and for each sex, varying rankings 

by region were identified. 

The variability in lung and bronchus cancer mortality observed among AI/ANs across 

regions (highest in Northern Plains, lowest in Southwest) is likely a consequence of the 

variability in tobacco use. Smoking prevalence among AI/AN adults is approximately 

20% in the Southwest but is approximately 44% in both the northern plains and Alaska 

regions.23 Regional variability in cancer mortality for other cancers is more difficult to 

explain and might be linked to differences in diet, prevalence of obesity and alcoholism, or access to care or later stage diagnoses. 

Limitations are well-recognized in using death certificate data to examine causespecific mortality. These include racial misclassification, errors in listing the decedent's 

residence at time of death, and errors in reporting the precise cause of death. Studies 

have reported that racial misclassification of AI/ANs on death certificates is a problem 

in certain regions of the country.25, 26, 37 Additionally, data indicate that AI/ANs die more 

often than whites of what is termed “signs, symptoms, and ill-defined conditions”.38 

These two latter problems lead to underestimations of the overall cancer mortality rates 

as well as underestimations of mortality for specific types of cancer. Our analysis provides evidence that miscellaneous malignant cancers are the leading cause of cancer 

8 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mortality among the AI/AN population of the Southwest (for females and both sexes 

combined). 

An additional limitation is that certain rates published in this monograph are based on 

only a limited number of cases. These have been included because AI/AN communities have expressed the need to no longer suppress these data; however, such rates 

should be interpreted with caution. The results of tests of statistical significance are 

noted for all comparisons with U.S. all-race rates in Tables 3–15. 

All rates in this report were age-adjusted using the 2000 U.S. standard population to 

make them more comparable with current publications. Rates from previous IHS cancer mortality reports were based on the 1970 U.S. standard population. Changing to 

the 2000 U.S. standard population affects the magnitude of the rates. Cancer mortality 

rates based on the 2000 U.S. population may be higher than those calculated using 

the U.S. 1970 population since the 2000 U.S. population has an older age distribution, 

and cancer is more prevalent in older persons. 

Although we used recently published census estimates, the degree to which errors 

might have occurred in the accurate counting of AI/ANs is not known precisely. However, evidence indicates that any errors would likely result in undercounting. Errors in 

using population figures that might be lower than the true numbers might lead to overestimation of the true cancer mortality rates for regions of the country where this was a 

problem. 

Despite these limitations and changes, the findings included here clearly demonstrate 

that AI/ANs across the country experience different cancer mortality patterns both between regions and in comparison with U.S. all-race rates, and that AI/ANs in the Southwest have markedly different cancer mortality patterns from other AI/ANs in the United 

States. 

To better understand the extent of cancer mortality among AI/ANs in the United States, 

further collaboration between CDC, IHS, and state vital records offices should be promoted and expanded. A study is underway that links IHS patient registration data with 

vital records data from approximately 25 states to identify AI/AN persons who have 

been misclassified as non-Native. Such collaborations can provide improved data for 

developing preventive programs and intervention strategies that should be targeted 

appropriately for specific populations. Improved cancer mortality data can illuminate 

the extent of the problem and help provide direction to decision makers regarding 

where to apply limited resources for the most beneficial impact. 

9 
REFERENCES
 

1.	 Grim C. IHS Marks 50 Years Providing Service. US Medicine. January 2006. 

2.	 Indian Health Service Fact Sheet http://info.ihs.gov/Files/IHSFactsJan2007.doc. Accessed June 15, 2007. 

3.	 PL (Public Law) 93 – 638. http://www.ihs.gov/NonMedicalPrograms/chr/pl93­

638.cfm. Accessed June 15, 2007. 

4.	 Indian Health Care Improvement Act http://info.ihs.gov/TreatiesLaws/ 

Treaties3.pdf. Accessed January 14, 2007. 

5.	 Indian Health Service: Area Offices and Facilities. http://www.ihs.gov/ 

FacilitiesServices/AreaOffices/AreaOffices_index.asp. Accessed May 20, 2007. 

6.	 Indian Health Service: Year 2007 Profile. http://info.ihs.gov/Files/ProfileSheetJan2007.doc. Accessed January 14, 2007. 

7.	 Indian Health Service: A Quick Look http://info.ihs.gov/Files/QuickLookJan2007.doc. Accessed June 14, 2007. 

8.	 Indian Health Service: Trends in Indian Health, 1998-1999. Rockville, MD; 

2000. 

9.	 Lanier AP, Kelly JJ, Maxwell J, McEvoy T, Homan C. Cancer in Alaska Native 

people, 1969-2003. Alaska Med. Jul-Sep 2006;48(2):30-59. 

10.	 Brown MO, Lanier AP, Becker TM. Colorectal cancer incidence and survival 

among Alaska Natives, 1969-1993. Int J Epidemiol. Jun 1998;27(3):388-396. 

11.	 Chao A, Becker TM, Jordan SW, Darling R, Gilliland FD, Key CR. Decreasing 

rates of cervical cancer among American Indians and Hispanics in New Mexico 

(United States). Cancer Causes Control. Mar 1996;7(2):205-213. 

12.	 Chao A, Gilliland FD, Hunt WC, Bulterys M, Becker TM, Key CR. Increasing incidence of colon and rectal cancer among Hispanics and American Indians in 

New Mexico (United States), 1969-94. Cancer Causes Control. Mar 1998;9 

(2):137-144. 

13.	 Eidson M, Becker TM, Wiggins CL, Key CR, Samet JM. Breast cancer among 

Hispanics, American Indians and non-Hispanic whites in New Mexico. Int J Epidemiol. Apr 1994;23(2):231-237. 

14.	 Lanier AP, Kelly JJ, Holck P, Smith B, McEvoy T, Sandidge J. Cancer incidence 

in Alaska Natives thirty-year report 1969-1998. Alaska Med. Oct-Dec 2001;43 

(4):87-115. 

10 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.	 Lanier AP, Kelly JJ, Smith B, et al. Alaska Native cancer update: incidence rates 

1989-1993. Cancer Epidemiol Biomarkers Prev. Sep 1996;5(9):749-751. 

16.	 Schiff M, Becker TM, Smith HO, Gilliland FD, Key CR. Ovarian cancer incidence 

and mortality in American Indian, Hispanic, and non-Hispanic white women in 

New Mexico. Cancer Epidemiol Biomarkers Prev. May 1996;5(5):323-327. 

17.	 Schiff M, Key CR, Gilliland FD, Becker TM. Ethnic differences in uterine corpus 

cancer incidence and mortality in New Mexico's American Indians, hispanics 

and non-Hispanic whites. Int J Epidemiol. Apr 1997;26(2):249-255. 

18.	 Wiggins CL, Becker TM, Key CR, Samet JM. Stomach cancer among New Mexico's American Indians, Hispanic whites, and non-Hispanic whites. Cancer Res. 

Mar 15 1989;49(6):1595-1599. 

19.	 Cobb N, Paisano RE. Patterns of cancer mortality among Native Americans. 

Cancer. Dec 1 1998;83(11):2377-2383. 

20.	 Espey D, Paisano RE, and Cobb N. Cancer Mortality among American Indians 

and Alaska Natives: Regional Differences, 1994-1998. Rockville, MD: Indian 

Health Service; 2003. 

21.	 Espey D, Paisano R, Cobb N. Regional patterns and trends in cancer mortality 

among American Indians and Alaska Natives, 1990-2001. Cancer. Mar 1 

2005;103(5):1045-1053. 

22.	 Garguillo P, Wingo P, Coates R, Thompson T. Recent trends in mortality rates 

for four major cancers, by sex and race/ethnicity--United States, 1990-1998. 

MMWR Morb Mortal Wkly Rep. Jan 25 2002;51(3):49-53. 

23.	 Espey DK, Wu XC, Swan J, et al. Annual report to the nation on the status of 

cancer, 1975-2004, featuring cancer in American Indians and Alaska Natives. 

Cancer. Oct 15 2007:2119-2152. 

24.	 Cobb N PR. Cancer Mortality among American Indians and Alaska Natives in 

the United States: Regional Differences in Indian Health, 1989-1993. Indian 

Health Service: Rockville, MD; 1997. 

25.	 Frost F, Shy KK. Racial differences between linked birth and infant death records in Washington State. Am J Public Health. Sep 1980;70(9):974-976. 

26.	 Harwell TS, Hansen D, Moore KR, Jeanotte D, Gohdes D, Helgerson SD. Accuracy of race coding on American Indian death certificates, Montana 1996-1998. 

Public Health Rep. Jan-Feb 2002;117(1):44-49. 

27.	 Valway S Kileen M, Paisano RE, Ortiz E. Cancer mortality among Native Americans in the United States: Regional Differences in Indian Health, 1984-1988 & 

Trends Over Time, 1968-1987. Indian Health Service: Rockville, MD; 1992. 

11 
28.	 Surveillance, Epidemiology, and End Results (SEER) Program 

(www.seer.cancer.gov) SEER*Stat Database: Mortality - All COD, Public-Use 

With County, Total U.S. (1990-2003) - Linked To County Attributes - Total U.S., 

1969-2003 Counties, National Cancer Institute, DCCPS, Surveillance Research 

Program, Cancer Statistics Branch, released April 2006. Underlying mortality 

data provided by NCHS (www.cdc.gov/nchs). 

29.	 1990-2003, Expanded Races: (White, Black, American Indian/Alaska Native, 

Asian/Pacific Islander) by Origin (Hispanic, Non-Hispanic). http:// 

seer.cancer.gov/popdata/download.html. Accessed Dec 11, 2006. 

30.	 Surveillance, Epidemiology, and End Results (SEER) Program. Statistical Resources. U.S. population data 1969-2004. http://seer.cancer.gov/resources. Accessed July 9, 2007. 

31.	 U.S. census populations with bridged race categories. http://www.cdc.gov/nchs/ 

about/major/dvs/popbridge/popbridge.htm. Accessed July 9, 2007. 

32.	 Denny CH, Holtzman D, Cobb N. Surveillance for health behaviors of American 

Indians and Alaska Natives. Findings from the Behavioral Risk Factor Surveillance System, 1997-2000. MMWR Surveill Summ. Aug 1 2003;52(7):1-13. 

33.	 Wong D SE, Paisano EL, Cheek JE Indian Health Surveillance Report— Sexually Transmitted Diseases 2004. Atlanta, GA: U.S. Department of Health and 

Human Services, Centers for Disease Control and Prevention and Indian Health 

Service; 2006. 

34.	 Adjusting for Miscoding of Indian Race on State Death Certificates. Rockville, 

MD: Division of Program Statistics, Indian Health Service; 1997. 

35.	 Fay MP, Feuer EJ. Confidence intervals for directly standardized rates: a 

method based on the gamma distribution. Stat Med. Apr 15 1997;16(7):791­

801. 

36.	 Breslow NE, Day N. Statistical methods in cancer research. Volume II ­

the design and analysis of cohort studies: Oxford University Press; 1991. 

37.	 Percy C, Stanek E, 3rd, Gloeckler L. Accuracy of cancer death certificates and 

its effect on cancer mortality statistics. Am J Public Health. Mar 1981;71(3):242­

250. 

38.	 Becker TM, Wiggins CL, Key CR, Samet JM. Symptoms, signs, and ill-defined 

conditions: a leading cause of death among minorities. Am J Epidemiol. Apr 

1990;131(4):664-668. 

12 
Table 1. Definition of geographic regions, corresponding IHS service 

populations, total AI/AN population of states included in regions, and 

service population percentage — 1999–2003 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Geographic 

region 

IHS service 

population 

estimates* 

Total AI/AN 

population 

estimates † 

Service 

population 

% of total 

AI/AN 

States (IHS administrative 

areas) § 

Alaska 108,462 108,462 100% AK (Alaska) 

East 103,149 682,523 15.1 % 

AL, AR, CT, DE, FL, GA, 

KY, LA, ME, MD, MA, MS, 

MO, NH, NJ, NY, NC, OH, 

PA, RI, SC, TN, VT, VA, 

WV, DC 

(Nashville) 

Northern 

Plains 265,912 451,769 58.9 % 

IL, IN, IA, MI, MN, MT, NE, 

ND, SD, WI, WY 

(Aberdeen, Bemidji, Billings) 

Pacific 

Coast 369,217 669,090 55.2 % CA, ID, OR, WA, HI (California, Portland) 

Southern 

Plains 327,262 498,368 65.7 % KS, OK, TX (Nashville, Oklahoma) 

Southwest 520,437 597,299 87.1 % 

AZ, CO, NV, NM, UT 

(Albuquerque, Navajo, 

Phoenix, Tucson) 

All regions 

combined 1,694,439 3,007,510 56.3 % 

* All population figures are derived from intercensal estimates and annualized for 1999–2003 (updated February 

2006).

† This total is derived from bridged single-race estimates. 

§ 

 Bolded states contain CHSDA counties. 

13 
Table 2. Cancer site groupings for ICD-10–coded mortality data 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cancer-related causes of death ICD-10 

All malignant cancers C00-C97 

Oral cavity and pharynx 

Lip C00 

Tongue C01–C02 

Salivary gland C07–C08 

Floor of mouth C04 

Gum and other mouth C03, C05–C06 

Nasopharynx C11 

Tonsil C09 

Oropharynx C10 

Hypopharynx C12–C13 

Other oral cavity and pharynx C14 

Digestive system 

Esophagus C15 

Stomach C16 

Small intestine C17 

Colon and rectum 

Colon excluding rectum C18, C26.0 

Rectum and rectosigmoid junction C19–C20 

Anus, anal canal and anorectum C21 

Liver and intrahepatic bile duct 

Liver C22.0, C22.2–C22.4, C22.7, C22.9 

Intrahepatic bile duct C22.1 

Gallbladder C23 

Other biliary C24 

Pancreas C25 

Retroperitoneum C48.0 

Peritoneum, omentum, and mesentery C45.1, C48.1–C48.2 

Other digestive organs C26.8–C26.9, C48.8 

14 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 2. Cancer site groupings for ICD-10–coded mortality data 

(continued) 

Cancer-related causes of death ICD-10 

Respiratory system 

Nose, nasal cavity, and middle ear C30–C31 

Larynx C32 

Lung and bronchus C34 

Pleura C38.4, C45.0 

Trachea, mediastinum, and other respiratory organs C33, C38.1–C38.3, C38.8, C39 

Bones and joints C40–C41 

Soft tissue, including heart C47, C49, C38.0, C45.2 

Skin, excluding basal and squamous 

Melanoma of the Skin 

Other nonepithelial skin 

C43 

C44, C46 

Breast C50 

Female genital system 

Cervix uteri 

Corpus and uterus, NOS* 

C53 

Corpus uteri C54 

Uterus, NOS* C55 

Ovary C56 

Vagina C52 

Vulva C51 

Other female genital organs C57–C58 

Male genital system 

Prostate C61 

Testis C62 

Penis C60 

Other male genital organs C63 

Urinary system 

Urinary bladder C67 

Kidney and renal pelvis C64–C65 

Ureter C66 

Other urinary organs C68 

Eye and orbit C69 

15 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 2. Cancer site groupings for ICD-10–coded mortality data 

(continued) 

Cancer-related causes of death ICD-10 

Brain and other nervous system C70, C71, C72 

Endocrine system 

Thyroid 

Other endocrine including thymus 

C73 

C37, C74–C75 

Lymphoma 

Hodgkin lymphoma 

Non-Hodgkin lymphoma 

C81 

C82–C85, C96.3 

Myeloma C90.0, C90.2 

Leukemia 

Lymphocytic leukemia 

Acute lymphocytic leukemia 

Chronic lymphocytic leukemia 

Other lymphocytic leukemia 

Myeloid and monocytic leukemia 

Acute myeloid 

Acute monocytic leukemia 

Chronic myeloid leukemia 

Other myeloid/monocytic leukemia 

Other leukemia 

Other acute leukemia 

Aleukemic, subleukemic and NOS* 

C91.0 

C91.1 

C91.2–C91.4, C91.7, C91.9 

C92.0, C92.4–C92.5, C94.0, C94.2 

C93.0 

C92.1 

C92.2–C92.3, C92.7, C92.9, C93.1–C93.2, C93.7, 

C93.9 

C94.4, C94.5, C95.0 

C90.1, C91.5, C94.1, C94.3, C94.7, C95.1, C95.2, 

C95.7, C95.9 

Mesothelioma C45 

Kaposi Sarcoma C46 

Miscellaneous malignant cancer C26.1, C45.7, C45.9, C76–C80, C88, C96.0–C96.2, 

C96.7, C96.9, C97 

* NOS = not otherwise specified. 

16 
 

 

 

Figure 4
 

Cancer mortality rate ratio for both sexes 

1999–2003, AI/AN compared with all U.S. races 

2.71 

1.70 

1.62 

1.58 

1.43 

1.01 

0.87 

0.83 

0.76 

0.76 

0.73 

0.71 

0.61 

0.0 0.5 1.0 1.5 2.0 2.5 3.0 

Gallbladder 

Stomach 

Kidney 

Liver 

Cervix 

Miscellaneous 

Colon/rectum 

All site 

Prostate 

Ovary 

Lung 

Pancreas 

Breast * 

* 

* 

* 

* 

* 

* 

* 

* 

* 

* 

* 

*AI/AN rate statistically different from U.S. all-race death rate. 

17 
 

 

 

 

 

 

 

 

Figure 5 

Cancer mortality rate ratio for males 

1999–2003, AI/AN compared with all U.S. races 

2.40 

1.69 

1.59 

1.43 

0.93 

0.86 

0.78 

0.74 

0.67 

0.61 

0.0 0.5 1.0 1.5 2.0 2.5 3.0 

Gallbladder 

Stomach 

Kidney 

Liver 

Miscellaneous 

Colon/rectum 

All site 

Prostate 

Lung 

Pancreas * 

* 

* 

* 

* 

* 

* 

* 

* 

*AI/AN rate statistically different from U.S. all-race death rate. 

Figure 6
 

Cancer mortality rate ratio for females 

1999–2003, AI/AN compared with all U.S. races 

3.13 

1.87 

1.84 

1.61 

1.37 

1.08 

0.87 

0.86 

0.80 

0.80 

0.76 

0.61 

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 

Gallbladder 

Liver 

Stomach 

Kidney 

Cervix 

Miscellaneous 

Colon/rectum 

All site 

Pancreas 

Lung 

Ovary 

Breast 

* 

* 

* 

* 

* 

* 

* 

* 

* 

* 

* 

*AI/AN rate statistically different from U.S. all-race death rate. 

18 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 7 

All site cancer mortality rates 

both sexes, 1999–2003 

0 50 100 150 200 250 300 350 

Northern Plains 

Alaska 

Southern Plains 

Pacific Coast 

East 

Southwest 

Rates per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (161.9) * 

All U.S. (195.7) 

* Denotes a significantly low er rate than the U.S. rate. 

For both sexes combined, the 1999– 

2003 age-adjusted 

cancer mortality rate 

for all cancers combined is 

161.9/100,000 

among the entire 

IHS service population. This rate is significantly lower than 

the U.S. all-race 

combined rate for 

both sexes. 

Regional rates demonstrate that both 

the Northern Plains 

and Alaska regions 

have significantly 

higher rates than the 

U.S. rate. The four 

remaining regions all 

have significantly 

lower rates than the 

U.S. rate for both 

sexes. 

Table 3 

Table 3 lists the 

total number of 

deaths caused 

by all cancers, 

1999–2003, as 

well as mortality 

rates by IHS 

region for both 

sexes combined, 

males, and females. 

Mortality rates 

are calculated 

per 100,000/ 

year and are 

age-adjusted to 

the 2000 U.S. 

population. 

Rates based on 

limited numbers 

of deaths should 

be interpreted 

with caution. 

All site cancer mortality rates and total number of deaths, 1999–2003 

Both sexes Males Females 

No. Rate No. Rate No. Rate 

U.S. all races 2,770,823 195.7 1,435,711 243.7 1,335,112 164.3 

All IHS regions 7,227 161.9* 3,638 191.2* 3,589 141.9* 

Alaska 660 242.3† 349 299.1† 311 205.4† 

East 411 139.1* 203 155.0* 208 127.9* 

Northern Plains 1,550 255.2† 774 305.5† 776 223.8† 

Pacific Coast 1,303 140.2* 652 159.4* 651 126.7* 

Southern Plains 1,586 154.5* 815 190.5* 771 131.2* 

Southwest 1,717 130.2* 845 151.4* 872 115.5* 

* Denotes a significantly lower rate than the U.S. rate. 

† Denotes a significantly higher rate than the U.S. rate. 

19 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 8 

All site cancer mortality rates 

males, 1999–2003 

0 50 100 150 200 250 300 350 

Northern Plains 

Alaska 

Southern Plains 

Pacific Coast 

East 

Southwest 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (191.2) * 

All U.S. (243.7) 

* Denotes a significantly low er rate than the U.S. rate. 

Figure 9 

All site cancer mortality rates 

females, 1999–2003 

0 50 100 150 200 250 300 350 

Northern Plains 

Alaska 

Southern Plains 

East 

Pacific Coast 

Southwest 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (141.9) * 

All U.S. (164.3) 

* Denotes a significantly low er rate than the U.S. rate. 

For males, the 

1999–2003 ageadjusted cancer 

mortality rate for all 

cancers is 

191.2/100,000 

among the entire 

IHS service population. This rate is significantly lower than 

the U.S. all-race 

combined rate for 

males. 

Regional rates reveal that both the 

Northern Plains and 

Alaska regions have 

significantly higher 

rates than the U.S. 

rate. The four remaining regions all 

have significantly 

lower rates than the 

U.S. rate for males. 

For females, the 

1999–2003 ageadjusted cancer 

mortality rate for all 

cancers is 

141.9/100,000 

among the entire 

IHS service population. This rate is significantly lower than 

the U.S. all-race 

combined rate for 

females. 

Regional rates reveal that both the 

Northern Plains and 

Alaska regions have 

significantly higher 

rates than the U.S. 

rate. The four remaining regions all 

have significantly 

lower rates than the 

U.S. rate for females. 

20 
 

Figure 10 

 

 

 

 

Stomach cancer mortality rates 

both sexes, 1999–2003 

0 5 10 15 20 

Alaska 

Southwest 

Northern Plains 

East 

Southern Plains 

Pacific Coast 

Rates per 100,000 per year, adjusted to 2000 U.S. population 

All U.S. (4.4) 

All IHS (7.5) † 

† Denotes a significantly higher rate than the U.S. rate. 

For both sexes combined, the 1999– 

2003 age-adjusted 

cancer mortality rate 

for stomach cancer 

is 7.5/100,000 

among the entire 

IHS service population. This rate is significantly higher than 

the U.S. all-race 

combined rate for 

both sexes. 

Regional rates reveal that the Alaska, 

Southwest, and 

Northern Plains regions have significantly higher rates 

than the U.S. rate for 

both sexes. 

Table 4 

Stomach cancer mortality rates and total number of de aths, 1999–2003 

 Both sexes Males Females 

 No. Rate No. Rate No. Rate 

 

U.S. all races 61,983 4.4 36,166 6.1 25,817 3.1 

All IHS regions 329 7.5† 190 10.3† 139 5.7† 

 

Alaska 46 15.7† 23 19.0† 23 14.0† 

East 15 4.9 10 7.1 5 3.1 

Northern Plains 48 7.7† 28 10.6† 20 5.9† 

Pacific Coast 37 4.0 21 5.1 16 3.2 

Southern Plains 48 4.7 28 6.7 20 3.5 

Southwest 135 11.0† 80 15.3† 55 8.0† 

 

 

 

† Denotes a significantly higher rate than the U.S. rate. 

Table 4 lists the 

total number of 

deaths caused 

by stomach cancer, 1999–2003, 

as well as mortality rates by 

IHS region for 

both sexes combined, males, 

and females. 

Mortality rates 

are calculated 

per 100,000/ 

year and are 

age-adjusted to 

the 2000 U.S. 

population. 

Rates based on 

limited numbers 

of deaths should 

be interpreted 

with caution. 

21 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 11 

Stomach cancer mortality rates 

males, 1999–2003 

0 5 10 15 20 

Alaska 

Southwest 

Northern Plains 

East 

Southern Plains 

Pacific Coast 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (10.3)† 

All U.S. (6.1) 

† Denotes a significantly higher rate than the U.S. rate. 

For males, the 

1999–2003 ageadjusted cancer 

mortality rate for 

stomach cancer is 

10.3/100,000 among 

the entire IHS service population. This 

rate is significantly 

higher than the U.S. 

all-race combined 

rate for males. 

Regional rates reveal that the Alaska, 

Southwest, and 

Northern Plains regions have significantly higher rates 

than the U.S. rate for 

males. 

Figure 12 

Stomach cancer mortality rates 

females, 1999–2003 

0 5 10 15 

Alaska 

Southwest 

Northern Plains 

Southern Plains 

Pacific Coast 

East 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All U.S. (3.1) 

All IHS (5.7) † 

† Denotes a significantly higher rate than the U.S. rate. 

For females, the 

1999–2003 ageadjusted cancer 

mortality rate for 

stomach cancer is 

5.7/100,000 among 

the entire IHS service population. This 

rate is significantly 

higher than the U.S. 

all-race combined 

rate for females. 

Regional rates reveal that the Alaska, 

Southwest, and 

Northern Plains regions have significantly higher rates 

than the U.S. rate for 

females. 

22 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 13 

Colon/rectum cancer mortality rates 

both sexes, 1999–2003 

0 10 20 30 40 50 

Alaska 

Northern Plains 

Southern Plains 

East 

Pacific Coast 

Southwest 

Rates per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (17.3) * 

All U.S. (20.0) 

* Denotes a significantly low er rate than the U.S. rate. 

For both sexes combined, the 1999– 

2003 age-adjusted 

cancer mortality rate 

for colon/rectum 

cancer is 

17.3/100,000 among 

the entire IHS service population. This 

rate is significantly 

lower than the U.S. 

all-race combined 

rate for both sexes. 

Regional rates reveal that both the 

Alaska and Northern 

Plains regions have 

significantly higher 

rates than the U.S. 

rate. The Southwest 

and Pacific Coast 

regions have significantly lower rates 

than the U.S. rate for 

both sexes. 

Table 5 

Table 5 lists the 

total number of 

deaths caused 

by colorectal 

cancer, 1999– 

2003, as well as 

mortality rates 

by IHS region for 

both sexes combined, males, 

and females. 

Mortality rates 

are calculated 

per 100,000/ 

year and are 

age-adjusted to 

the 2000 U.S. 

population. 

Rates based on 

limited numbers 

of deaths should 

be interpreted 

with caution. 

Colon/rectum cancer mortality rates and total numb

1999–2003 

er of deaths, 

Both sexes Males Females 

No. Rate No. Rate No. Rate 

U.S. all races 283,850 20.0 141,487 24.3 142,363 17.0 

All IHS regions 753 17.3* 394 20.9* 359 14.8* 

Alaska 90 35.5† 47 45.4† 43 30.5† 

East 49 16.6 21 13.8* 28 17.9 

Northern Plains 159 28.6† 80 37.1† 79 24.4† 

Pacific Coast 144 16.4* 81 21.0 63 13.0* 

Southern Plains 179 17.8 92 21.5 87 15.1 

Southwest 132 9.4* 73 11.4* 59 7.9* 

* Denotes a significantly lower rate than the U.S. rate.

† Denotes a significantly higher rate than the U.S. rate. 

23 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 14 

Colon/rectum cancer mortality rates 

males, 1999–2003 

0 10 20 30 40 50 

Alaska 

Northern Plains 

Southern Plains 

Pacific Coast 

East 

Southwest 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (20.9) * 

All U.S. (24.3) 

* Denotes a significantly low er rate than the U.S. rate. 

For males, the 

1999–2003 ageadjusted cancer 

mortality rate for colon/rectum cancer is 

20.9/100,000 among 

the entire IHS service population. This 

rate is significantly 

lower than the U.S. 

all-race combined 

rate for males. 

Regional rates reveal that both the 

Alaska and Northern 

Plains regions have 

significantly higher 

rates than the U.S. 

rate. The Southwest 

and East regions 

have significantly 

lower rates than the 

U.S. rate for males. 

Figure 15 

Colon/rectum cancer mortality rates 

females, 1999–2003 

0 10 20 30 40 50 

Alaska 

Northern Plains 

East 

Southern Plains 

Pacific Coast 

Southwest 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (14.8) * 

All U.S. (17.0) 

* Denotes a significantly low er rate than the U.S. rate. 

For females, the 

1999–2003 ageadjusted cancer 

mortality rate for colon/rectum cancer is 

14.8/100,000 over 

the entire IHS service population. This 

rate is significantly 

lower than the U.S. 

all-race combined 

rate for females. 

Regional rates reveal that both the 

Alaska and Northern 

Plains regions have 

significantly higher 

rates than the U.S. 

rate. The Southwest 

and Pacific Coast 

regions have significantly lower rates 

than the U.S. rate for 

females. 

24 
Figure 16 

 

 

 

 

 

Liver and intrahepatic duct cancer 

mortality rates, both sexes, 1999–2003 

0 5 10 15 

Southwest 

Alaska 

Northern Plains 

Pacific Coast 

Southern Plains 

East 

Rates per 100,000 per year, adjusted to 2000 U.S. population 

All U.S. (4.8) 

All IHS (7.6) † 

† Denotes a significantly higher rate than the U.S. rate. 

For both sexes combined, the 1999– 

2003 age-adjusted 

cancer mortality rate 

for liver and intrahepatic duct cancer 

is 7.6/100,000 

among the entire 

IHS service population. This rate is significantly higher than 

the U.S. all-race 

combined rate for 

both sexes. 

Regional rates reveal that four regions (Southwest, 

Alaska, Northern 

Plains, Pacific 

Coast) have significantly higher rates 

than the U.S. rate for 

both sexes. 

Table 6 

Liver and intrahepatic duct cancer mortality rates and total number of deaths, 

1999–2003 

 Both sexes Males Females 

 No. Rate No. Rate No. Rate 

 

U.S. all races 67,402 4.8 42,841 7.0 24,561 3.0 

All IHS regions 346 7.6† 212 10.0† 134 5.6† 

 

Alaska 26 9.3† 11 8.4 15 10.1† 

East 17 5.4 11 7.0 6 3.9 

Northern Plains 58 8.9† 42 13.6† 16 4.9 

Pacific Coast 63 6.6† 32 6.9 31 6.1† 

Southern Plains 61 5.8 37 7.7 24 4.2 

Southwest 121 9.4† 79 13.4† 42 6.1† 

 

 

 

Table 6 lists the 

total number of 

deaths caused 

by liver and intrahepatic duct 

cancer, 1999– 

2003, as well as 

mortality rates 

by IHS region for

both sexes combined, males, 

and females. 

Mortality rates 

are calculated 

per 100,000/ 

year and are 

age-adjusted to 

the 2000 U.S. 

population. 

Rates based on 

limited numbers 

of deaths should 

be interpreted 

with caution. † Denotes a significantly higher rate than the U.S. rate. 

25 
Figure 17 

 

 

 

 

 

 

 

 

 

 

 

 

 

Liver and intrahepatic duct cancer 

mortality rates, males, 1999–2003 

0 5 10 15 

Northern Plains 

Southwest 

Alaska 

Southern Plains 

East 

Pacific Coast 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All U.S. (7.0) 

All IHS (10.0) † 

† Denotes a significantly higher rate than the U.S. rate. 

For males, the 

1999–2003 ageadjusted cancer 

mortality rate for 

liver and intrahepatic 

duct cancer is 

10.0/100,000 among 

the entire IHS service population. This 

rate is significantly 

higher than the U.S. 

all-race combined 

rate for males. 

Regional rates reveal that both the 

Northern Plains and 

Southwest regions 

have significantly 

higher rates than the 

U.S. rate for males. 

Figure 18 

Liver and intrahepatic duct cancer 

mortality rates, females, 1999–2003 

0 5 10 15 

Alaska 

Pacific Coast 

Southwest 

Northern Plains 

Southern Plains 

East 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All U.S. (3.0) 

All IHS (5.6) † 

† Denotes a significantly higher rate than the U.S. rate. 

For females, the 

1999–2003 ageadjusted cancer 

mortality rate for colon/rectum cancer is 

5.6/100,000 among 

the entire IHS service population. This 

rate is significantly 

higher than the U.S. 

all-race combined 

rate for females. 

Regional rates reveal that the Alaska, 

Pacific Coast, and 

Southwest regions 

have significantly 

higher rates than the 

U.S. rate for females. 

26 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 19 

Gallbladder cancer mortality rates 

both sexes, 1999–2003 

0 1 2 3 4 5 6 

Southwest 

Northern Plains 

East 

Alaska 

Southern Plains 

Pacific Coast 

Rates per 100,000 per year, adjusted to 2000 U.S. population 

All U.S. (0.7) 

All IHS (1.9) † 

† Denotes a significantly higher rate than the U.S. rate. 

For both sexes combined, the 1999– 

2003 age-adjusted 

cancer mortality rate 

for gallbladder cancer is 1.9/100,000 

among the entire 

IHS service population. This rate is significantly higher than 

the U.S. all-race 

combined rate for 

both sexes. 

Regional rates reveal that Southwest 

and Northern Plains 

regions have significantly higher rates 

than the U.S. rate for 

both sexes. 

Table 7 

Table 7 lists the 

total number of 

deaths caused 

by gallbladder 

cancer, 1999– 

2003, as well as 

mortality rates 

by IHS region for 

both sexes combined, males, 

and females. 

Mortality rates 

are calculated 

per 100,000/ 

year and are 

age-adjusted to 

the 2000 U.S. 

population. 

Rates based on 

limited numbers 

of deaths should 

be interpreted 

with caution. 

Gallbladder cancer mortality rates and total number of deaths, 

1999–2003 

Both sexes Males Females 

No. Rate No. Rate No. Rate 

U.S. all races 9,801 0.7 2,868 0.5 6,933 0.8 

All IHS regions 79 1.9† 19 1.2† 60 2.5† 

Alaska 3 1.2 1 0.8 2 1.5 

East 3 1.4 1 1.5 2 1.5 

Northern Plains 10 1.7† 2 0.7 8 2.4† 

Pacific Coast 5 0.6 0 0.0 5 1.0 

Southern Plains 9 1.0 3 0.9 6 1.1 

Southwest 49 4.0† 12 2.5† 37 5.1† 

† Denotes a significantly higher rate than the U.S. rate. 

27 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 20 

Gallbladder cancer mortality rates 

males, 1999–2003 

0 1 2 3 4 5 6 

Southwest 

East 

Southern Plains 

Alaska 

Northern Plains 

Pacific Coast 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All U.S. (0.5) 

All IHS (1.2) † 

† Denotes a significantly higher rate than the U.S. rate. 

For males, the 

1999–2003 ageadjusted cancer 

mortality rate for 

gallbladder cancer is 

1.2/100,000 among 

the entire IHS service population. This 

rate is significantly 

higher than the U.S. 

all-race combined 

rate for males. 

Regional rates reveal that the Southwest region has a 

significantly higher 

rate than the U.S. 

rate for males. 

Figure 21 

Gallbladder cancer mortality rates 

females, 1999–2003 

0 1 2 3 4 5 6 

Southwest 

Northern Plains 

East 

Alaska 

Southern Plains 

Pacific Coast 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All U.S. (0.8) 

All IHS (2.5) † 

† Denotes a significantly higher rate than the U.S. rate. 

For females, the 

1999–2003 ageadjusted cancer 

mortality rate for 

gallbladder cancer is 

2.5/100,000 among 

the entire IHS service population. This 

rate is significantly 

higher than the U.S. 

all-race combined 

rate for females. 

Regional rates reveal that the Southwest and Northern 

Plains regions have 

significantly higher 

rates than the U.S. 

rate for females. 

28 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 22 

Pancreas cancer mortality rates 

both sexes, 1999–2003 

0 5 10 15 20 25 

Alaska 

Northern Plains 

Southwest 

Pacific Coast 

East 

Southern Plains 

Rates per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (7.5) * 

All U.S. (10.5) 

* Denotes a significantly low er rate than the U.S. rate. 

For both sexes combined, the 1999– 

2003 age-adjusted 

cancer mortality rate 

for pancreatic cancer is 7.5/100,000 

among the entire 

IHS service population. This rate is significantly lower than 

the U.S. all-race 

combined rate for 

both sexes. 

Regional rates reveal that the Southern Plains, East, 

Pacific Coast, and 

Southwest regions 

have significantly 

lower rates than the 

U.S. rate for both 

sexes. 

Table 8 

Pancreas cancer mortality rates and total number of deaths, 1999–2003 

Both sexes Males Females 

No. Rate No. Rate No. Rate 

U.S. all races 149,254 10.5 72,815 12.2 76,439 9.2 

All IHS regions 329 7.5* 151 7.5* 178 7.4* 

Alaska 37 12.4 23 20.0† 14 7.7 

East 20 6.4* 10 6.8 10 6.1 

Northern Plains 56 8.4 26 7.9* 30 8.5 

Pacific Coast 61 7.0* 22 4.8* 39 8.4 

Southern Plains 60 6.1* 27 5.7* 33 5.9* 

Southwest 95 7.7* 43 7.9* 52 7.5 

Table 8 lists the 

total number of 

deaths caused 

by pancreatic 

cancer, 1999– 

2003, as well as 

mortality rates 

by IHS region for 

both sexes combined, males, 

and females. 

Mortality rates 

are calculated 

per 100,000/ 

year and are 

age-adjusted to 

the 2000 U.S. 

population. 

Rates based on 

limited numbers 

of deaths should 

be interpreted 

with caution. * Denotes a significantly lower rate than the U.S. rate.

† Denotes a significantly higher rate than the U.S. rate. 

29 
 

 

 

 

 

 

 

 

 

 

 

Figure 23 

Pancreas cancer mortality rates 

males, 1999–2003 

0 5 10 15 20 25 

Alaska 

Northern Plains 

Southwest 

East 

Southern Plains 

Pacific Coast 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (7.5) * 

All U.S. (12.2) 

* Denotes a significantly low er rate than the U.S. rate. 

For males, the 

1999–2003 ageadjusted cancer 

mortality rate for 

pancreatic cancer is 

7.5/100,000 among 

the entire IHS service population. This 

rate is significantly 

lower than the U.S. 

all-race combined 

rate for males. 

Regional rates reveal that the Alaska 

region has a significantly higher rate 

than the U.S. rate. 

Four other regions 

(Pacific Coast, 

Southern Plains, 

Southwest, and 

Northern Plains) 

have significantly 

lower rates than the 

U.S. rate for males. 

Figure 24 

Pancreas cancer mortality rates 

females, 1999–2003 

0 5 10 15 20 25 

Northern Plains 

Pacific Coast 

Alaska 

Southwest 

East 

Southern Plains 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (7.4) * 

All U.S. (9.2) 

* Denotes a significantly low er rate than the U.S. rate. 

For females, the 

1999–2003 ageadjusted cancer 

mortality rate for 

pancreatic cancer is 

7.4/100,000 among 

the entire IHS service population. This 

rate is significantly 

lower than the U.S. 

all-race combined 

rate for females. 

Regional rates reveal that the Southern Plains region 

has a significantly 

lower rate than the 

U.S. rate for females. 

30 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 25 

Lung cancer mortality rates 

both sexes, 1999–2003 

0 20 40 60 80 100 

Northern Plains 

Alaska 

Southern Plains 

East 

Pacific Coast 

Southwest 

Rates per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (40.0) * 

All U.S. (55.1) 

* Denotes a significantly low er rate than the U.S. rate. 

For both sexes combined, the 1999– 

2003 age-adjusted 

cancer mortality rate 

for lung cancer is 

40.0/100,000 among 

the entire IHS service population. This 

rate is significantly 

lower than the U.S. 

all-race combined 

rate for both sexes. 

Regional rates reveal that the Northern Plains region 

has a significantly 

higher rate than the 

U.S. rate for both 

sexes. Four other 

regions (Southwest, 

Pacific Coast, East, 

and Southern 

Plains) have significantly lower rates 

than the U.S. rate for 

both sexes. 

Table 9 

Lung cancer mortality rates and total number of deaths, 1999–2003 

Both sexes Males Females 

No. Rate No. Rate No. Rate 

U.S. all races 779,076 55.1 450,199 74.8 328,877 41.0 

All IHS regions 1763 40.0* 951 50.0* 812 32.8* 

Alaska 173 63.8 103 82.0 70 49.2 

East 123 42.2* 66 51.6* 57 35.5 

Northern Plains 505 84.2† 257 100.3† 248 73.2† 

Pacific Coast 368 40.3* 189 47.1* 179 35.5 

Southern Plains 439 43.0* 243 56.2* 196 33.6* 

Southwest 155 12.4* 93 17.9* 62 8.4* 

Table 9 lists the 

total number of 

deaths caused 

by lung cancer, 

1999–2003, as 

well as mortality 

rates by IHS 

region for both 

sexes combined, 

males, and females. 

Mortality rates 

are calculated 

per 100,000/ 

year and are 

age-adjusted to 

the 2000 U.S. 

population. 

Rates based on 

limited numbers 

of deaths should 

be interpreted 

with caution. * Denotes a significantly lower rate than the U.S. rate.

† Denotes a significantly higher rate than the U.S. rate. 

31 
 

 

 

 

 

 

 

 

 

 

 

Figure 26 

Lung cancer mortality rates 

males, 1999–2003 

0 20 40 60 80 100 

Northern Plains 

Alaska 

Southern Plains 

East 

Pacific Coast 

Southwest 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (50.0) * 

All U.S. (74.8) 

* Denotes a significantly low er rate than the U.S. rate. 

For males, the 

1999–2003 ageadjusted cancer 

mortality rate for 

lung cancer is 

50.0/100,000 among 

the entire IHS service population. This 

rate is significantly 

lower than the U.S. 

all-race combined 

rate for males. 

Regional rates reveal that the Northern Plains region 

has a significantly 

higher rate than the 

U.S. rate for males. 

Four other regions 

(Southwest, Pacific 

Coast, East, and 

Southern Plains) 

have significantly 

lower rates than the 

U.S. rate for males. 

Figure 27 

Lung cancer mortality rates 

females, 1999–2003 

0 20 40 60 80 100 

Northern Plains 

Alaska 

East 

Pacific Coast 

Southern Plains 

Southwest 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (32.8) * 

All U.S. (41.0) 

* Denotes a significantly low er rate than the U.S. rate. 

For females, the 

1999–2003 ageadjusted cancer 

mortality rate for 

lung cancer is 

32.8/100,000 among 

the entire IHS service population. This 

rate is significantly 

lower than the U.S. 

all-race combined 

rate for females. 

Regional rates reveal that the Northern Plains region 

has a significantly 

higher rate than the 

U.S. rate for females. The Southwest and Southern 

Plains regions have 

significantly lower 

rates than the U.S. 

rate for females. 

32 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 28 

Breast cancer mortality rates 

females, 1999–2003 

0 5 10 15 20 25 30 35 

Alaska 

Northern Plains 

Southern Plains 

East 

Southwest 

Pacific Coast 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (15.9) * 

All U.S. (26.0) 

* Denotes a significantly low er rate than the U.S. rate. 

For females, the 

1999–2003 ageadjusted cancer 

mortality rate for 

breast cancer is 

15.9/100,000 among 

the entire IHS service population. This 

rate is significantly 

lower than the U.S. 

all-race combined 

rate for females. 

Regional rates reveal that five regions 

(Pacific Coast, 

Southwest, East, 

Southern Plains, and 

Northern Plains) 

have significantly 

lower rates than the 

U.S. rate for females. 

Table 10 

Breast cancer mortality rates and total number of deaths, 1999–2003 

Both sexes Males Females 

No. Rate No. Rate No. Rate 

U.S. all races 209,518 14.8 1,975 0.3 207,543 26.0 

All IHS regions 437 9.0* 2 0.1 435 15.9* 

Alaska 38 11.4 0 0.0 38 21.2 

East 30 9.5* 1 0.7 29 16.5* 

Northern Plains 77 11.6 0 0.0 77 20.3* 

Pacific Coast 72 7.3* 0 0.0 72 13.0* 

Southern Plains 110 10.4* 1 0.4 109 18.0* 

Southwest 110 7.4* 0 0.0 110 13.2* 

Table 10 lists 

the total number 

of deaths 

caused by 

breast cancer, 

1999–2003, as 

well as mortality 

rates by IHS 

region for both 

sexes combined, 

males, and females. 

Mortality rates 

are calculated 

per 100,000/ 

year and are 

age-adjusted to 

the 2000 U.S. 

population. 

Rates based on 

limited numbers 

of deaths should 

be interpreted * Denotes a significantly lower rate than the U.S. rate. 

with caution. 

33 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 29 

Cervical cancer mortality rates 

females, 1999–2003 

0 1 2 3 4 5 6 7 8 9 10 

Northern Plains 

Southwest 

Southern Plains 

East 

Alaska 

Pacific Coast 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (3.7) † 

All U.S. (2.7) 

† Denotes a significantly higher rate than the U.S. rate. 

For females, the 

1999–2003 ageadjusted cancer 

mortality rate for cervical cancer is 

3.7/100,000 among 

the entire IHS service population. This 

rate is significantly 

higher than the U.S. 

all-race combined 

rate for females. 

Regional rates reveal that the Northern Plains and 

Southwest regions 

have significantly 

higher rates than the 

U.S. rate for females. 

Table 11 

Cervical cancer mortality rates and total number of deaths, 1999–2003 

Females 

No. Rate 

U.S. all races 20,367 2.7 

All IHS regions 114 3.7† 

Alaska 4 2.2 

East 6 3.1 

Northern Plains 35 7.9† 

Pacific Coast 9 1.3 

Southern Plains 25 3.7 

Southwest 35 4.1† 

Table 11 lists 

the total number 

of deaths 

caused by cervical cancer, 

1999–2003, as 

well as mortality 

rates by IHS 

region for females. 

Mortality rates 

are calculated 

per 100,000/ 

year and are 

age-adjusted to 

the 2000 U.S. 

population. 

Rates based on 

limited numbers 

of deaths should 

be interpreted 

with caution. † Denotes a significantly higher rate than the U.S. rate. 

34 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 30 

Ovarian cancer mortality rates 

females, 1999–2003 

0 5 10 15 

Southwest 

Northern Plains 

Pacific Coast 

Southern Plains 

East 

Alaska 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (6.8) * 

All U.S. (8.9) 

* Denotes a significantly low er rate than the U.S. rate. 

For females, the 

1999–2003 ageadjusted cancer 

mortality rate for 

ovarian cancer is 

6.8/100,000 among 

the entire IHS service population. This 

rate is significantly 

lower than the U.S. 

all-race combined 

rate for females. 

Regional rates reveal that the Alaska 

and Southern Plains 

regions have significantly lower rates 

than the U.S. rate for 

females. 

Table 12 

Ovarian cancer mortality rates and total number of deaths, 1999–2003 

Females 

No. Rate 

U.S. all races 71,440 8.9 

All IHS regions 177 6.8* 

Alaska 7 3.5* 

East 6 4.0 

Northern Plains 30 8.4 

Pacific Coast 37 6.6 

Southern Plains 29 5.2* 

Southwest 68 8.7 

* Denotes a significantly lower rate than the U.S. rate. 

Table 12 lists 

the total number 

of deaths 

caused by ovarian cancer, 

1999–2003, as 

well as mortality 

rates by IHS 

region for females. 

Mortality rates 

are calculated 

per 100,000/ 

year and are 

age-adjusted to 

the 2000 U.S. 

population. 

Rates based on 

limited numbers 

of deaths should 

be interpreted 

with caution. 

35 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 31 

Prostate cancer mortality rates 

males, 1999–2003 

0 5 10 15 20 25 30 35 40 45 

Northern Plains 

Alaska 

Southern Plains 

Southwest 

East 

Pacific Coast 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (21.5) * 

All U.S. (29.1) 

* Denotes a significantly low er rate than the U.S. rate. 

For males, the 

1999–2003 ageadjusted cancer 

mortality rate for 

prostate cancer is 

21.5/100,000 among 

the entire IHS service population. This 

rate is significantly 

lower than the U.S. 

all-race combined 

rate for males. 

Regional rates reveal that the Northern Plains region 

has a significantly 

higher rate than the 

U.S. rate for males. 

Four regions (Pacific 

Coast, East, Southwest, and Southern 

Plains) have significantly lower rates 

than the U.S. rate for 

males. 

Table 13 

Prostate cancer mortality rates and total number of deaths, 1999–2003 

Males 

No. Rate 

U.S. all races 153,525 29.1 

All IHS regions 293 21.5* 

Alaska 14 23.5 

East 15 16.1* 

Northern Plains 69 41.6† 

Pacific Coast 44 15.3* 

Southern Plains 69 21.7* 

Southwest 82 19.2* 

* Denotes a significantly lower rate than the U.S. rate.

† Denotes a significantly higher rate than the U.S. rate. 

Table 13 lists 

the total number 

of deaths 

caused by prostate cancer, 

1999–2003, as 

well as mortality 

rates by IHS 

region for males. 

Mortality rates 

are calculated 

per 100,000/ 

year and are 

age-adjusted to 

the 2000 U.S. 

population. 

Rates based on 

limited numbers 

of deaths should 

be interpreted 

with caution. 

36 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 32 

Kidney and renal pelvis cancer mortality rates 

both sexes, 1999–2003 

0 4 8 12 16 

Alaska 

Southwest 

Northern Plains 

Southern Plains 

East 

Pacific Coast 

Rates per 100,000 per year, adjusted to 2000 U.S. population 

All U.S. (4.2) 

All IHS (6.8) † 

† Denotes a significantly higher rate than the U.S. rate. 

For both sexes combined, the 1999– 

2003 age-adjusted 

cancer mortality rate 

for kidney and renal 

pelvis cancer is 

6.8/100,000 among 

the entire IHS service population. This 

rate is significantly 

higher than the U.S. 

all-race combined 

rate for both sexes. 

Regional rates reveal that four regions (Alaska, 

Southwest, Northern 

Plains, and Southern 

Plains) have significantly higher rates 

than the U.S. rate for 

both sexes. 

Table 14 

Kidney and renal pelvis cancer mortality rates and total 

1999–2003 

number of deaths 

Both sexes Males Females 

No. Rate No. Rate No. Rate 

U.S. all races 59,381 4.2 36,894 6.1 22,487 2.8 

All IHS regions 320 6.8† 202 9.7† 118 4.5† 

Alaska 23 9.0† 17 14.9† 6 4.3 

East 13 4.5 7 5.4 6 3.7 

Northern Plains 55 7.9† 36 11.3† 19 4.9† 

Pacific Coast 35 3.9 21 5.5 14 2.7 

Southern Plains 82 7.4† 55 10.8† 27 4.4† 

Southwest 112 8.3† 66 11.1† 46 6.1† 

Table 14 lists 

the total number 

of deaths 

caused by kidney and renal 

pelvis cancer, 

1999–2003, as 

well as mortality 

rates by IHS 

region for both 

sexes combined, 

males, and females. 

Mortality rates 

are calculated 

per 100,000/ 

year and are 

age-adjusted to 

the 2000 U.S. 

population. 

Rates based on 

limited numbers 

of deaths should † Denotes a significantly higher rate than the U.S. rate.
 

be interpreted
 

with caution.
 

37 
 

 

 

 

 

 

 

 

 

 

 

Figure 33 

Kidney and renal pelvis cancer mortality rates 

males, 1999–2003 

0 4 8 12 16 

Alaska 

Northern Plains 

Southwest 

Southern Plains 

Pacific Coast 

East 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All U.S. (6.1) 

All IHS (9.7) † 

† Denotes a significantly higher rate than the U.S. rate. 

For males, the 

1999–2003 ageadjusted cancer 

mortality rate for kidney and renal pelvis 

cancer is 

9.7/100,000 among 

the entire IHS service population. This 

rate is significantly 

higher than the U.S. 

all-race combined 

rate for males. 

Regional rates reveal that four regions (Alaska, 

Northern Plains, 

Southwest, and 

Southern Plains) 

have significantly 

higher rates than the 

U.S. rate for males. 

Figure 34 

Kidney and renal pelvis cancer mortality rates 

females, 1999–2003 

0 4 8 12 16 

Southwest 

Northern Plains 

Southern Plains 

Alaska 

East 

Pacific Coast 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All U.S. (2.8) 

All IHS (4.5) † 

† Denotes a significantly higher rate than the U.S. rate. 

For females, the 

1999–2003 ageadjusted cancer 

mortality rate for kidney and renal pelvis 

cancer is 

4.5/100,000 among 

the entire IHS service population. This 

rate is significantly 

higher than the U.S. 

all-race combined 

rate for females. 

Regional rates reveal that three regions (Southwest, 

Northern Plains, and 

Southern Plains) 

have significantly 

higher rates than the 

U.S. rate for females. 

38 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 35 

Miscellaneous malignant cancer mortality rates 

both sexes, 1999–2003 

0 10 20 30 40 

Alaska 

Northern Plains 

Southwest 

Southern Plains 

Pacific Coast 

East 

Rates per 100,000 per year, adjusted to 2000 U.S. population 

All U.S. (15.4) 

All IHS (15.6) 

For both sexes combined, the 1999– 

2003 age-adjusted 

cancer mortality rate 

for miscellaneous 

malignant cancer is 

15.6/100,000 among 

the entire IHS service population. This 

rate is not significantly different than 

the U.S. all-race 

combined rate for 

both sexes. 

Regional rates reveal that the Alaska 

and Northern Plains 

regions have significantly higher rates 

than the U.S. rate for 

both sexes. The 

East and Pacific 

Coast regions have 

significantly lower 

rates than the U.S. 

rate for both sexes. 

Table 15 

Miscellaneous malignant cancer mortality rates and total 

1999–2003 

number of deaths 

Both sexes Males Females 

No. Rate No. Rate No. Rate 

U.S. all races 218,485 15.4 114,094 19.4 104,391 12.6 

All IHS regions 674 15.6 347 18.1 327 13.6 

Alaska 79 30.1† 45 38.0† 34 23.6† 

East 27 10.0* 10 8.2* 17 11.3 

Northern Plains 134 22.8† 71 27.0† 63 19.6† 

Pacific Coast 94 10.7* 49 12.4* 45 9.3 

Southern Plains 146 14.4 81 19.1 65 11.3 

Southwest 194 15.2 91 16.0 103 14.3 

* Denotes a significantly lower rate than the U.S. rate.

† Denotes a significantly higher rate than the U.S. rate. 

Table 15 lists 

the total number 

of deaths 

caused by miscellaneous malignant cancer, 

1999–2003, as 

well as mortality 

rates by IHS 

region for both 

sexes combined, 

males, and females. 

Mortality rates 

are calculated 

per 100,000/ 

year and are 

age-adjusted to 

the 2000 U.S. 

population. 

Rates based on 

limited numbers 

of deaths should 

be interpreted 

with caution. 

39 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 36 

Miscellaneous malignant cancer mortality rates 

males, 1999–2003 

0 10 20 30 40 

Alaska 

Northern Plains 

Southern Plains 

Southwest 

Pacific Coast 

East 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All IHS (18.1) 

All U.S. (19.4) 

For males, the 

1999–2003 ageadjusted cancer 

mortality rate for 

miscellaneous malignant cancer is 

18.1/100,000 among 

the entire IHS service population. This 

rate is not significantly different than 

the U.S. all-race 

combined rate for 

males. 

Regional rates reveal that the Alaska 

and Northern Plains 

regions have significantly higher rates 

than the U.S. rate for 

males. The East and 

Pacific Coast regions have significantly lower rates 

than the U.S. rate for 

males. 

Figure 37 

Miscellaneous malignant cancer mortality rates 

females, 1999–2003 

0 10 20 30 40 

Alaska 

Northern Plains 

Southwest 

East 

Southern Plains 

Pacific Coast 

Rate per 100,000 per year, adjusted to 2000 U.S. population 

All U.S. (12.6) 

All IHS (13.6) 

For females, the 

1999–2003 ageadjusted cancer 

mortality rate for 

miscellaneous malignant cancer is 

13.6/100,000 among 

the entire IHS service population. This 

rate is not significantly different than 

the U.S. all-race 

combined rate for 

females. 

Regional rates reveal that the Alaska 

and Northern Plains 

regions have significantly higher rates 

than the U.S. rate for 

females. 

40 
Table 16. Five leading causes of cancer mortality by average annual age-adjusted rates,* 

1999–2003, by IHS geographic region and sex, compared with U.S. All races population. 

Region Both sexes Males Females 

U.S. All races Lung 55.1 Lung 74.8 Lung 41.0 

Colon/rectum 20.0 Prostate 29.1 Breast 26.0 

Miscellaneous 15.4 Colon/rectum 24.3 Colon/rectum 17.0 

Breast 14.8 Miscellaneous 19.4 Miscellaneous 12.6 

 Prostate 10.9 Pancreas 12.2 Pancreas 9.2 

All IHS regions Lung 40.0 Lung 50.0 Lung 32.8 

Colon/rectum 17.3 Prostate 21.5 Breast 15.9 

Miscellaneous 15.6 Colon/rectum 20.9 Colon/rectum 14.8 

 Breast 9.0 Miscellaneous 18.1 Miscellaneous 13.6 

 Prostate 8.3 Stomach 10.3 Pancreas 7.4 

Alaska Lung 63.8 Lung 82.0 Lung 49.2 

Colon/rectum 35.5 Colon/rectum 45.4 Colon/rectum 30.5 

Miscellaneous 30.1 Miscellaneous 38.0 Miscellaneous 23.6 

 Stomach 15.7 Prostate 23.5 Breast 21.2 

 Pancreas 12.4 Pancreas 20.0 Stomach 14.0 

East Lung 42.2 Lung 51.6 Lung 35.5 

Colon/rectum 16.6 Prostate 16.1 Colon/rectum 17.9 

Miscellaneous 10.0 Colon/rectum 13.8 Breast 16.5 

 Breast 9.5 Miscellaneous 8.2 Miscellaneous 11.3 

 Pancreas 6.4 Leukemia 7.7 Pancreas 6.1 

Northern Plains Lung 84.2 Lung 100.3 Lung 73.2 

Colon/rectum 28.6 Prostate 41.6 Colon/rectum 24.4 

Miscellaneous 22.8 Colon/rectum 37.1 Breast 20.3 

 Prostate 15.3 Miscellaneous 27.0 Miscellaneous 19.6 

 Breast 11.6 Liver 13.6 Pancreas 8.5 

Pacific Coast Lung 40.3 Lung 47.1 Lung 35.5 

Colon/rectum 16.4 Colon/rectum 21.1 Colon/rectum 13.0 

Miscellaneous 10.7 Prostate 15.3 Breast 13.0 

 Breast 7.3 Miscellaneous 12.4 Miscellaneous 9.3 

 Pancreas 7.0 Leukemia 7.4 Pancreas 8.4 

Southern Plains Lung 43.0 Lung 56.2 Lung 33.6 

Colon/rectum 17.8 Prostate 21.7 Breast 18.0 

Miscellaneous 14.4 Colon/rectum 21.5 Colon/rectum 15.1 

 Breast 10.4 Miscellaneous 19.1 Miscellaneous 11.3 

 Prostate 7.9 Kidney 10.8 Pancreas 5.9 

Southwest Miscellaneous 15.2 Prostate 19.2 Miscellaneous 14.3 

 Lung 12.4 Lung 17.9 Breast 13.2 

 Stomach 11.0 Miscellaneous 16.0 Ovary 8.7 

Colon/rectum 9.4 Stomach 15.3 Lung 8.4 

 Liver 9.4 Liver 13.4 Stomach 8.0 

*All rates are per 100,000 population/year, adjusted to the 2000 U.S. standard population. 

41