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RESEARCH 

Patterns of Cancer Related Health 

Disparities in Arizona 
Ken Batai*, Francine C. Gachupin1, Antonio L. Estrada2, David O. Garcia3, Jorge Gomez4, Rick A. Kittles5  

*Division of Urology, Department of Surgery, University of Arizona, University of Arizona Cancer Center, 

1515 N. Campbell Ave., P.O. Box 245024, Tucson, AZ 85724. 1Department of Family and Community 

Medicine, University of Arizona, P.O. Box 245052, Tucson, AZ 85724. 2Department of Mexican American 

Studies, University of Arizona, Cesar E. Chavez Building, 1110 E. James E. Rogers Way, P.O. Box 210023, 

Tucson, AZ 85721. 3Department of Health Promotion Sciences, University of Arizona, Mel and Enid 

Zuckerman College of Public Health, 3950 S. Country Club, Suite 330, Tucson, AZ 85714. 4Department of 

Community, Environment, and Policy, 1295 N. Martin Ave., PO Box: 210202, Tucson, AZ 85724. 5Division of 

Health Equities, Department of Population Sciences, City of Hope Comprehensive Cancer Center, 1500 E. 

Duarte Rd, Duarte, CA 91010-3000 

*Corresponding author email: kbatai@email.arizona.edu. 

ABSTRACT 
Cancer incidence rates vary regionally among American Indians (AIs) and Latinos. The goal of this was 

to identify areas of research necessary to reduce cancer health disparities in AIs and Latinos, the two 

major racial/ethnic minority groups in Arizona. In an effort to better understand cancer health 

disparities, cancer incidence rates in AIs and Latinos in Arizona were compared to non-Hispanic Whites 

(NHWs). Age-adjusted incidence rates (per 100,000) were obtained from the Arizona Cancer Registry 

and the North American Association of Central Cancer Registries. Spearman’s rank test was used to 

examine correlation between county-level cancer incidence rates and socio-demographic factors. AIs 

and Latinos had lower incidence rates of screening for detectable cancers than NHWs. Among older 

men (age ≥65), however, AIs and Latinos had similar prostate cancer incidence rates to NHWs. Some of 

less common cancers, such as kidney, stomach, liver, and gallbladder, were more frequently diagnosed 

in AIs and Latinos than NHWs. AIs and Latinos were more likely to be diagnosed with advanced cancer 

stage, except for cervical cancer. Correlations between prostate and breast cancer incidence rates and 

percent urban residents as well as correlations between incidence rates of these two cancer types and 

population size were significantly positive. Poverty levels were inversely correlated with colorectal and 

lung cancer incidence rates. Our review of cancer incidence rates suggests that socio-demographic 

factors, such as population size (rural/urban) and poverty levels, have influenced cancer detection and 

incidence rates in Arizona. 

KEYWORDS: Cancer Disparity, Health Disparity, American Indians, Latinos, Cancer Incidence 

Citation: Batai et al (2019) Patterns of Cancer Related Health Disparities in Arizona. Cancer Health 

Disparities 2:e1-e20. doi:10.9777/chd.2019.1008.



 
 
 
 
 

 

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INTRODUCTION 

Nationally, cancer is the second leading cause of 

death after heart disease (Kochanek et al., 2016), 

but in Arizona, cancer was the leading cause of 

death in 2015 among Latinos and non-Hispanic 

Whites (NHWs). Cancer is the second leading 

cause of death among American Indians (AIs) and 

African Americans (AAs) (Bureau of Public Health 

Statistics). Cancer incidence and mortality varies 

across racial/ethnic groups and geographic 

regions in the U.S. (Jemal et al., 2017; Mokdad et 

al., 2017). Cancer incidence and mortality also 

varies among AIs by Indian Health Service regions 

and among Latino subgroups (e.g., Mexican 

Americans, Puerto Ricans, and Cubans) has been 

reported (Borrell and Crawford, 2009; Pinheiro et 

al., 2009; Pinheiro et al., 2011; White et al., 2011; 

White et al., 2014). In the Southwest region of the 

United States (U.S.), cancer incidence and mortality 

rates, especially rates for lung, prostate, breast and 

colorectal cancer, are lower in AIs than NHWs 

(White et al., 2014). Among Latinos, Mexican 

Americans have lower cancer incidence rates that 

other Latino subgroups or NHWs (Pinheiro et al., 

2009), but they also have lower survival rates for 

common cancers than NHWs (Pinheiro et al., 2011; 

White et al., 2011). Furthermore, AIs and Latinos 

are more likely to be diagnosed with advanced 

stage cancer than NHWs (Clegg et al., 2002; 

Hoffman et al., 2014; Hoffman et al., 2001; Iqbal et 

al., 2015). Lower cancer survival rates may be 

attributed to delayed diagnosis among these 

medically underserved populations. However, the 

reasons for the variations in incidence rates are 

not fully understood.  

Arizona is uniquely situated to investigate cancer 

health disparities focusing on AIs and Latinos. 

Arizona has the third largest population of AIs in 

the U.S. (Norris et al., 2012). There are 21 federally 

recognized AI tribes in Arizona and approximately 

353,000 AIs live in Arizona (about 5.5% of total 

Arizona population) (Norris et al., 2012). The 

largest tribe is Navajo, and their reservation is 

located in northern Arizona, New Mexico, Utah, 

and Colorado. Tohono O’odham is the second 

largest tribe in Arizona and their reservation is east 

of Tucson and northern Mexico. Several Apache 

tribes have their reservation on the central-eastern 

part of Arizona. However, many AIs live in urban 

areas, such as Phoenix and Tucson, rather than 

remote rural areas. AIs living in urban areas and 

on reservations have varying degrees of issues 

related to access to health care, such as social 

structural, physical (transportation and physical 

distance), supportive, and cultural barriers (Call et 

al., 2006; Itty et al., 2014).  

Arizona is also one of four U.S.-Mexico border 

states, along with California, Texas, and New 

Mexico. Latinos constitute the largest racial/ethnic 

minority group in Arizona, which accounts for 

approximately 30% (1.8 million) of the Arizona 

residents (Ennis et al., 2011). Mexican Americans 

are the largest Latino subgroup in Arizona 

(1,657,668). Many Latinos live in urban areas and 

southern Arizona. Over 30% of residents in 

southern Arizona counties along the border are 

Latinos, and over 50% of residents in two rural 

counties, Santa Cruz and Yuma, that border with 

Mexico are Latinos. Like AIs, Latinos face multiple 

barriers related to health care access, and 

undocumented immigrants faces even more 

barriers to health care, such as lack of 

documentations to receive health insurance 

(Ortega et al., 2015).  

The goal of this paper was to identify areas of 

research necessary to reduce cancer health 



 
 
 
 
 

 

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disparities. In an effort to further understand 

cancer health disparities, cancer incidence rates 

among AIs and Latinos in Arizona were compared 

to NHWs and AAs with a focus on common types 

of cancer (breast, prostate, lung, and colorectal) 

and cancers that disproportionately affect AIs and 

Latinos (kidney, liver, stomach, cervical, myeloma, 

gallbladder, and uterine cancer). This paper 

focuses on AIs and Latinos, the two major 

racial/ethnic minority groups in Arizona. Other 

racial/ethnic minority groups including AAs, Asian 

Americans, and Native Hawaiian and other Pacific 

Islanders account for less than 5% of Arizona 

population (approximately 4.5%, 3.5%, and 0.5% 

respectively). 

METHODS 
Incidence Rates 

The cancer incidence data was retrieved in 

November and December 2016 from the Arizona 

Cancer Registry (ACR) and North American 

Association of Central Cancer Registries 

(NAACCR). To compare cancer incidence rates 

among racial/ethnic groups and among Arizona 

counties, age-adjusted incidence rates (per 

100,000 using the 2000 U.S. standard population) 

between 2004 and 2013 for each racial/ethnic 

group and county in Arizona were obtained from 

the ACR. Age-adjusted incidence rates between 

1995 and 2003 were also obtained from the ACR 

to examine cancer incidence trends for each 

racial/ethnic group. The data on cancer incidence 

in Asian Americans and Pacific Islanders were 

analyzed but not used due to both the small 

number of cancer cases and the small statewide 

population size. From the NAACCR, cancer 

incidence rates with 95% confidence interval (CI) 

stratified based on age group (age <65 vs. age 

≥65) and stage at diagnosis data (number of 

cases) between 2009 and 2013 were also obtained 

to reflect recent screening recommendations. 

Cancer incidence rates and 95% CI for each stage 

was retrieved from the NAACCR in March 2018. 

Socio-demographic Factors 

To compare the cancer incidence rate and socio-

demographic factors, county-level percent urban 

residents, population size, poverty rates, median 

income, and high school graduation rates were 

obtained. First, percent urban population for 15 

Arizona counties were obtained from 2010 Census. 

Second, population size based on 2010 census 

data was obtained from Arizona State 

Employment and Population Statistics. The data on 

poverty rates (all ages) and median income in 2014 

was obtained from the U.S. Census Bureau Small 

Area Income and Poverty Estimates (SAIPE). The 

2015 five-year high school graduation rates were 

also obtained from the Arizona Department of 

Education. Arizona Behavioral Risk Factor 

Surveillance System (BRFSS) data between 2010 

and 2014 was reviewed and a proportion (%) and 

95% CI of individuals who have barriers to health 

care (e.g., poverty, lack of health insurance, and 

not having usual source of health care) and who 

have had breast, colorectal, prostate, and cervical 

cancer screening were obtained.  

Statistical Methods 

Incidence rate ratios (IRRs) between AIs and NHWs 

and between Latinos and NHWs were calculated 

stratified by Medicare eligible age (<65 and ≥65) 

to examine if IRRs were significantly different for 

the younger and older age groups. IRRs were 

calculated by dividing the reported incidence rate 

in AIs or Latinos by the incidence rate in NHWs. 

We used 95% CI to evaluate statistical difference in 

incidence rates. Spearman’s correlation was used 

to assess the correlation of cancer incidence rates 

with Arizona county population sizes, poverty 



 
 
 
 
 

 

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rates, median incomes, and high school 

graduation rates. From number of cases for each 

diagnostic stage obtained from NAACCR, chi-

square test was used to test if diagnosis with 

localized or distant cancers were more frequent in 

AIs and Latinos. The two-tail test was used for 

Spearman’s correlation and chi-square test. 

RESULTS 
Cancer Incidence Rate and Stage 

We first examined differences in cancer incidence 

among racial/ethnic groups in the ten-year period 

between 2004 and 2013 (Figure 1). AIs and Latinos 

had significantly lower incidence rates than NHW 

and AAs for common screen detectable cancer 

(breast, prostate, and colorectal cancer) and lung 

cancer. In Latinos and NHWs, breast cancer 

incidence was higher than prostate cancer 

incidence. On the other hand, in AIs and AAs, 

prostate cancer incidence rate was higher than 

breast cancer incidence. Prostate cancer in AA 

men had the highest incidence rate. Some of less 

common types of cancer were more frequent in 

AIs, Latinos, and AAs than NHWs. AIs had a 

significantly higher incidence of kidney cancer, 

uterine cancer, liver cancer, stomach cancer, 

gallbladder cancer, and myeloma than NHWs. 

Latinos had significantly higher incidence of kidney 

cancer, cervical cancer, liver cancer, stomach 

cancer, and gallbladder cancer. AIs had a higher 

cervical cancer incidence rate than NHWs and 

AAs, but it was not statistically significant. AIs had 

slightly higher prostate cancer incidence rate than 

Latinos (statistically not significant), but breast 

cancer, lung cancer, and male colorectal cancer 

incidence rates for AIs were significantly lower than 

for Latinos. When stratified by gender, males had 

higher incidence of cancer than females. Kidney 

cancer incidence was very high in AI men (1.9 fold 

higher in AIs than in NHWs), and was the second 

most commonly diagnosed cancer among them.  

Figure 1. Age-adjusted Cancer Incidence Rates (per 100,000) between 2004 and 2013 in Arizona * indicates 

statistically significant different incidence rate compared to NHW. 

 

IRRs between AIs and NHWs and between Latinos 

and NHWs were examined stratified by age of 

diagnosis (<65 compared to ≥65) for four 

common cancers (breast, prostate, lung, and 

colorectal) and cervical cancer (Table 1). The IRRs 

were different between the younger age group 

and the older age group for prostate cancer 

(AI/NHW and Latino/NHW), lung cancer 

(Latino/NHW among men), colorectal cancer 

(AI/NHW among women), and cervical cancer 

(Latina/NHW). AIs had significantly lower prostate 

cancer incidence rate in the younger group, but 



 
 
 
 
 

 

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AIs and NHWs had similar incidence rates in the 

older group. The gap in the prostate cancer 

incidence rates between Latinos and NHWs also 

decreased in the older age group (IRR of 0.67 in 

the younger group compared to 0.91 in the order 

group). The difference in lung cancer incidence 

rate between Latino and NHW men also 

decreased from IRR of 0.46 in the younger group 

to 0.69 in the older group. On the other hand, AI 

women had a similar colorectal cancer incidence 

rate as did NHW women in the younger age 

group (IRR 1.05), but significantly lower incidence 

rate in the older age group (IRR 0.65). IRR for 

cervical cancer between Latina and NHW was 

moderately high (IRR 1.32), but even bigger 

incidence rate difference was observed in the 

older age group (IRR 2.01). 

Between 1995 and 2013, overall incidence rate of 

all cancer types combined declined for NHW, 

Latino, and AA men, reflecting the decline in 

incidence rate of three major cancer types in men 

(prostate, lung and colorectal) (Figure 2, 

Supplementary Figure 1). The prostate and lung 

cancer incidence followed national trends and 

declined for NHW, Latino, and AA men. Colorectal 

cancer incidence also declined for NHW men, but 

not for other racial/ethnic groups. 

Overall cancer incidence did not change for NHW, 

Latina, and AA women. Colorectal cancer 

incidence declined for NHW women, but it did not 

change for Latinas or AA women. Incidence of two 

other major caner types (breast and lung) did not 

change for NHW, Latina, and AA women. Overall 

cancer incidence slightly increased for AIs during 

this period. Colorectal cancer incidence increased 

for AI women. Breast cancer incidence rate did not 

change. Among AI men, incidence rate for 

prostate, colorectal, and lung cancer did not 

change. Over time, as the prostate and colorectal 

cancer incidence rates in NHW and AA men and 

the colorectal cancer rate in NHW women 

declined, the differences in prostate and colorectal 

cancer incidence rates among racial/ethnic groups 

narrowed. Incidence rates of two less common 

types of cancer, kidney and liver cancer, increased 

in all the racial/ethnic groups. 

Incidence rates for each stage of diagnosis were 

reviewed for five cancer types, breast, prostate, 

lung, colorectal, and cervical cancer (Supplementary 

Table 1). We also examined the proportion of 

individuals diagnosed in each stage (Supplementary 

Figure 2). The incidence rates for each stage 

generally reflect the overall incidence rates for these 

cancer types exhibiting overall lower incidence rates 

for AIs and Latinos compared to NHW while a 

higher proportion of AIs and Latinos were 

diagnosed with advanced stage cancer, except for 

cervical cancer. One exception is incidence rate for 

distant prostate cancer. AIs and Latinos had lower 

overall prostate cancer incidence rate than NHWs, 

but they had higher incidence rate for distant 

(metastatic) prostate cancer than NHWs. Distant 

prostate cancer was more common among AIs and 

Latinos (17% and 8% respectively) than NHWs (5%). 

Incidence rate of distant breast cancer was lower in 

AI women compared to NHW women, but a 

significantly higher proportion of AI women had 

distant breast cancer (8% in AIs compared to 5% in 

NHW). Latina women had similar incidence rates for 

distant breast and colorectal cancer to NHW 

women, but a proportion of Latina women with 

distant breast and colorectal cancer was higher 

than that of NHW. Latinos and AIs have lower 

incidence rates of distant lung cancer. However, a 

higher proportion of Latino men and AI women 

had distant lung cancer compared to NHW men 

and women. 



 
 
 
 
 

 

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Table 1. Comparison of Cancer Incidence among AIs, Latinos, and NHWs in Two Age Groups  

(Age-adjusted incidence rate per 100,000 between 2009-2013 Based on 2000 US Standard Population). 

  Age <65 Age ≥65 

  Incidence Rate IRR Incidence Rate IRR 

Cancer Type Gender AI Latino NHW AI/NHW Latino/NHW AI Latino NHW AI/NHW Latino/NHW 

Breast Female 

39.3 

(34.8-44.2) 

57.0 (54.5-

59.7) 

77.4 (75.6-

79.3) 0.51* 0.74* 

157.2 (128.4-

191.0) 

292.7 (273.3-

313.3) 

405.4 (396.7-

414.2) 0.39* 0.72* 

Prostate Male 

16.4 

(13.5-19.9) 

25.2 (23.5-

27.1) 

37.5 (36.4-

38.6) 0.44* 0.67* 

434.0 (374.9-

500.5) 

375.0 (349.7-

402.0) 

412.2 (402.8-

421.8) 1.05 0.91* 

Lung and 

Bronchus Male 

5.2 (3.6-

7.3) 8.0 (7.1-9.1) 

17.3 (16.6-

18.1) 0.30* 0.46* 

127.0 (95.7-

166.5) 

257.7 (235.9-

281.3) 

372.2 (363.1-

381.5) 0.34* 0.69* 

 Female 

6.8 (5.0-

9.1) 

6.8 (6.0-

7.8) 

15.1 (14.4-

15.8) 0.45* 0.45* 

103.9 (80.3-

132.5) 

159.8 (145.2-

175.5) 

298.7 (291.2-

306.4) 0.35* 0.53* 

Colorectal Male 

16.9 (13.9-

20.4) 

17.9 (16.4-

19.4) 

16.6 (15.8-

17.4) 1.02 1.08 

125.7 (95.5-

163.9) 

217.6 (197.6-

239.3) 

191.4 (184.8-

198.1) 0.66* 1.14 

 Female 

13.5 (10.9-

16.5) 

12.7 (11.5-

14.0) 

12.8 (12.0-

13.5) 1.05 0.99 

98.5 (75.4-

126.7) 

141.1 (127.3-

155.9) 

152.6 (147.3-

158.1) 0.65* 0.92 

Cervix Uteri Female 

5.4 (3.9-

7.5) 

7.8 (6.9-

8.8) 

5.9 (5.3-

6.4) 0.92 1.32* 

12.0 (5.1-

24.4) 

14.9 (10.8-

20.2) 7.4 (6.3-8.7) 1.62 2.01* 

Numbers in parentheses indicate 95% confidence interval. 

AI/NHW – incidence rate in AI / Incidence rate in NHW 

Latino/NHW – Incidence rate in Latino / Incidence rate in NHW 

* Significant difference in incidence rate based 95% confidence interval 



 
 
 
 
 

 

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Figure 2. Trends in Overall Cancer Incidence in Arizona between 1995 and 2013 

 

Impacts of Socio-Demographic Factors 

We compared cancer incidence rate between 

2004 and 2013 with percent urban residents, 

population size, median income, and high school 

graduation rate in Arizona counties for four 

common cancers and cervical cancer. Counties 

with high percent of urban residents and large 

population size had significantly higher breast and 

prostate cancer incidence rate (Supplementary 

Table 2). Strong positive correlations between 

prostate cancer incidence rate and population size 

were observed (Spearman’s correlation rho=0.775, 

P=0.001). The correlation was significant, even 

when NHWs and Latinos were analyzed 

separately. Poverty levels were inversely correlated 

with prostate, colorectal, and lung cancer 

incidence rate among men (P<0.05). The strongest 

correlation was observed for NHW men and 

colorectal cancer (Spearman’s correlation rho=-

0.747, P=0.001). Colorectal cancer incidence rates 

among men also increased with median income 

among men (P<0.05). Cervical cancer incidence 

rate was significantly inversely correlated with 

population size for NHW women. However, overall 

there were a small number of cases and three 

small counties had less than ten cases within each 

county as well as a large incidence rate with a very 

large 95% CI. Five-year high school graduate rates 

were not correlated with incidence rates of any 

cancer types. 

Arizona BRFSS 

The Arizona 2014 BRFSS results show that AIs and 

Latinos have more barriers to health care than 

NHWs. Compared to NHWs, a higher proportion 

of AIs and Latinos reported living below poverty 

line and not having health insurance 

(Supplementary Table 3). More Latinos also 

reported not being able to afford health care than 

NHWs (23.1% vs. 12.6%). A significantly smaller 

proportion of AIs and Latinos had usual source of 

health care (having primary care providers as a 

main source of health care) than NHWs and have 

had a preventative check-up in the past year. AAs 

were more likely than NHWs to report living below 

poverty level, but they were more likely to have a 

preventive check-up. While AI and Latina women 

had higher breast and cervical cancer screening 

rates than NHWs, AIs and Latinos had lower colon 

and prostate cancer screening rate than NHWs. It 

also should be noted that some risk factors of 

cancer are more prevalent in AIs and Latinos than 

NHWs. For example, obesity is more prevalent in 



 
 
 
 
 

 

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AIs and Latinos than NHWs (44.9% in AIs, 33.8% in 

Latinos, and 26.4% in NHWs). Smoking rates, on 

the other hand, were lower in AIs (12.0%) and 

Latinos (14.0%) than in NHWs (17.5%).  

DISCUSSION 

Cancer incidence rates were reviewed as a first 

step to understand cancer health disparities 

among AIs and Latinos in Arizona. Our review of 

cancer incidence rates suggests that many socio-

demographic factors may have influenced the 

cancer detection and reported cancer incidence 

rates in AIs and Latinos. Cancer incidence trend as 

well as observed differences between incidence 

rate of each stage at diagnosis and a proportion of 

patients diagnosed in each stage are reflective of 

differences in cancer screening participation in AIs, 

Latinos, NHWs, and AAs. Decline in prostate and 

colorectal incidence rates in NHW and AA men 

generally reflect changes in screening 

participations. Decline in prostate cancer screening 

due to a recent recommendation against prostate 

specific antigen (PSA) screening reduced prostate 

cancer diagnosis, while high colon cancer 

screening uptake increased removal of pre-

cancerous polyps reducing colorectal cancer 

incidence. On the other hand, continuously low 

screening participation in AIs may have resulted in 

persistently low screening detectable cancer 

incidence rates. Colon cancer screening rate 

among Latinos is also low, and colorectal 

incidence rate did not change over time. Although 

AIs and Latinos have lower cancer incidence rates, 

when they are diagnosed, a higher proportion of 

them was diagnosed with advanced stage cancer 

as reported in other studies (Clegg et al., 2002; 

Siegel et al., 2015).  

Population size (urban vs. rural) and poverty levels 

within given counties, physician and screening 

facility availability, and health care coverage are 

interconnected factors that influence cancer 

screening, detection, stage at diagnosis, cancer 

care, and ultimately mortality (Faruque et al., 2015; 

Odisho et al., 2010; Stimpson et al., 2012; 

Tatalovich et al., 2015; Tian et al.). Issues related to 

health care access in AIs and Latinos in the 

younger age group (age <60) may have caused 

less frequent PSA testing and lower detection of 

prostate cancer among younger AI and Latino 

men compared to the older AI and Latino men in 

Medicare eligible age group (≥65). In the Arizona 

2010 BRFSS, a smaller proportion of AI and Latino 

men reported ever having had a PSA test than 

NHWs men. Limited availability of urologists and 

primary care physicians in rural counties may also 

have reduced prostate cancer detections, 

especially in early stage. High incidence rates of 

distant prostate cancer in AIs and Latinos further 

support low screening rate influencing the prostate 

cancer diagnosis patterns. 

The reason for lower colorectal cancer incidence in 

AIs in the older age compared to younger is not 

known, but educational level and ability to speak 

English may have influenced their knowledge on 

colon cancer screening, screening participation 

and detection among the older AI women 

(Sanderson et al., 2011). Colorectal cancer 

incidence and screening rates among AIs and 

Latinos in Arizona may also reflect issues related to 

health care access. Increasing colorectal cancer 

screening rate in NHWs reduced colorectal cancer 

incidence rate in NHWs. AIs and Latinos have 

lower colorectal cancer screening rates than 

NHWs, and their incidence rate did not change 

over time. Higher percentage of Latinas were 

diagnosed with distant colorectal cancer than 



 
 
 
 
 

 

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NHW women. Low cancer, especially colorectal 

cancer, incidence rates were observed in Arizona 

counties with high poverty rates. High poverty 

rates are usually found in rural counties where 

large AI reservations are located or a high 

proportion of residents are Latinos. Low density of 

high quality health care facilities in rural areas with 

high poverty rates may have reduced cancer 

screening and detection. However, we did not 

observe significant correlation between poverty 

levels and colorectal cancer incidence rate in 

Latinos.  

Women’s health programs that provided service to 

low-income uninsured and underinsured women 

have been successful (Lantz and Mullen, 2015), 

and AI and Latino women in Arizona have similar 

or higher breast and cervical cancer screening rate 

when compared with NHWs women. However, 

higher proportion of AIs and Latinas were 

diagnosed with distant breast cancer than NHWs. 

AI and Latina women living rural areas of Arizona 

are less likely to receive breast and cervical cancer 

screening than in AI and Latina women living 

urban areas (Nuño et al., 2012). It is likely that AIs 

and Latinas tended to be diagnosed with more 

advance stage cancer due to lower screening rates 

in these rural areas with high poverty levels. 

Cancer incidence rate in AIs and Latinos are 

generally lower than NHWs, but incidence rate of 

less common types of cancer was higher in AIs 

and Latinos. Kidney and liver cancer incidence 

rates were particularly high in AIs and Latinos 

compared to NHWs and increasing. Kidney and 

liver cancer as well as other less common types of 

cancer, such as stomach and uterine cancer, that 

are disproportionately affecting AIs and Latinos, 

are linked to obesity (Lauby-Secretan et al., 2016), 

and obesity is more prevalent in AIs and Latinos in 

Arizona. Although there is an effort to provide 

service to medically underserved women (Lantz 

and Mullen, 2015), AI and Latino men may have 

heavier burden of cancer than AI and Latina 

women. Cancer incidence rates in men are 

generally higher than women. In the general 

population, lung and breast cancer have a higher 

mortality rate than other types of cancers, but in 

Arizona AIs, prostate cancer mortality rate is 

higher than the mortality rate for other types of 

cancers (Arizona Cancer Registry, 2013). Despite 

the high cancer burden, AI and Latino men have 

low health care utilization (Livingstone et al., 2008; 

Rhoades, 2003).  

One of limitations of this study is that this was an 

ecological study and cancer incidence trends and 

correlations with socio-demographic factors were 

investigated, and this study did not investigate 

how individual level socio-demographic, 

behavioral factors, and cultural values affected 

cancer screening behavior and detection. The 

independent effects of these correlated factors will 

be explored in our future studies. 

After reviewing cancer incidence rates among AIs 

and Latinos in Arizona, we identified several issues 

that need to be addressed through research. First, 

it is necessary to develop programs to increase 

cancer screening among AIs and Latinos. AIs and 

Latinos are less likely to participate in colon and 

prostate cancer screening, and they are more 

likely to be diagnosed with advanced cancer. 

Because of potential harms including high rate of 

false positive, overdiagnosis and overtreatment, 

and treatment complication, AI and Latino men 

should be encouraged to discuss the benefit and 

risk of prostate cancer screening with their health 

care provider (U. S. Preventive Services Task Force, 

2018). Second, it is necessary to find effective ways 



 
 
 
 
 

 

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to reduce barriers to health care, especially in rural 

areas. AIs and Latinos have more barriers to health 

care and are less likely to receive medical care. 

Racial/ethnic minority individuals living in rural 

areas may have additional barriers to health care. 

Third, some of risk factors for cancer, such as 

obesity and diabetes, are more prevalent in AIs 

and Latinos and need to be reduced. Culturally 

tailored intervention and education programs 

need to be developed to increase cancer 

screening and reduce cancer risk factors. Fourth, 

AI and Latino men are less likely to receive health 

care. Programs targeting to AI and Latino men, 

especially low-income uninsured and underinsured 

men, need to be developed to improve their 

health care utilization and cancer screening. 

CONCLUSION 

Differences in incidence rates among racial/ethnic 

groups reflect differences in socio-demographic 

factors (poverty, population density, and age), 

health care access, screening participation, and/or 

lifestyle. AIs and Latinos in Arizona have multiple 

barriers to health care and barriers to health care 

influence their cancer screening participation, 

detection, care, and ultimately mortality. 

Acknowledgements 

We would like to acknowledge the individual 

affected by cancer represented in our data. We 

are grateful for the editorial assistance from Alicia 

Allen, PhD, Amit Algotar, MD, Carol Howe, MD, 

Jerome Koleski, MD, and Jessie Pettit, MD. This 

research was funded by the Arizona Area Health 

Education Centers Program Career Development 

Award, the Arizona Cancer Center Health 

Disparities Program, Institutional Research Grant 

number IRG-16-124-37-IRG from the American 

Cancer Society, and the Partnership for Native 

American Cancer Prevention (NACP), funded 

under parallel grants, U54CA143924 (University of 

Arizona Cancer Center) and U54CA143925 

(Northern Arizona University). 

ONLINE SOURCE 

Arizona Cancer Registry Database Query System 

http://healthdata.az.gov/query/module_selection/a

zcr/AzCRSelection.html 

North American Association of Central Cancer 

Registries Fast Stats 

https://faststats.naaccr.org/ 

Conflict of interest 
The authors declare that no competing or conflict of 

interests exists. The funders had no role in study 

design, writing of the manuscript, or decision to 

publish. 

Authors’ contributions 
KB, FCG, ALE, and RAK conceptualized the study. KB 

performed analysis.  All the authors contributed to 

interpretation of analysis results, writing, and editing. 

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Supplementary Materials 

Supplementary Figure 1. Trends in Cancer Incidence in Arizona between 1995 and 2013 (Age-adjusted 

incidence rate per 100,000) 

 

  
 

  

 
 

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Supplementary Figure 2. Comparison of Stage at Diagnosis between 2009 and 2013 (Percentage). * 

indicates statistically significant difference compared to NHW with P<0.05. 

 

  
 

  

 

55* 

36 

8* 

59* 

35 

6* 

67 

29 

5 

0

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Localized Regional Distant

Breast - Female 

75 

8 

17* 

78 

14 
8* 

80 

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Localized Regional Distant

Prostate 

21 
16 

64 

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62* 

21 
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Localized Regional Distant

Lung - Male 

23 

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61* 

25 25 

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27 25 

48 

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Localized Regional Distant

Lung - Female 



 
 
 
 
 

 

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Supplementary Table 1. Comparison of Stage at Diagnosis between 2010 and 2014: Incidence rate (IR) and 95% CI.  * 

indicates significantly higher incidence rate compared to NHW 

   Localized Regional Distant 

      IR 95% CI IR 95% CI IR 95% CI 

Breast Female NHW 73.8 72.3-75.3 33.3 32.2-34.4 5.6 5.2-6.0 

  Latina 50.4 47.9-53.0 26.4 24.7-28.3 4.9 4.2-5.8 

  AI 29.7 25.8-34.2 18.8 15.8-22.4 3.2 2.0-4.9 

44 

33 

22 

42 

35 

23 

45 

35 

20 

0

10

20

30

40

50

Localized Regional Distant

Colorectal - Male 

41 41 

18 

38 38 

24* 

45 

35 

20 

0

10

20

30

40

50

Localized Regional Distant

Colorectal - Female 

61 

39 

51 

38 

11 

50 

35 

15 

0

10

20

30

40

50

60

70

Localized Regional Distant

Cervical 



 
 
 
 
 

 

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Prostate Male NHW 54.8 53.5-56.0 10.6 10.0-11.1 4.2 3.8-4.52 

  Latino 39.7 37.2-42.4 7.8 6.8-9.0 5.5 4.51-6.7 

  AI 34.7 29.5-40.7 3.5 2.1-5.8 11.3* 8.1-15.5 

Lung Male NHW 10.4 9.9-11.0 12.1 11.5-12.7 25.8 25.0-26.7 

  Latino 4.7 3.8-5.9 6.6 5.4-7.9 18.5 16.6-20.6 

  AI 4.2 2.4-6.9 3.2 1.7-5.8 10.9 8.0-14.8 

 Female NHW 11.2 10.6-11.7 10.2 9.7-10.7 20.0 19.3-20.8 

  Latina 5.4 4.6-6.4 5.3 4.4-6.3 10.7 9.6-12.1 

  AI 2.9 1.7-4.7 3.2 1.9-5.0 10.0 7.6-12.9 

Colorectal Male NHW 14.6 14.0-15.3 12.1 11.5-12.7 6.9 6.5-7.4 

  Latino 14.9 13.3-16.6 14.1 12.5-15.8 8.1 7.0-9.4 

  AI 11.1 8.4-14.7 9.9 7.4-13.2 6.1 4.1-8.9 

 Female NHW 11.8 11.2-12.4 9.4 8.8-9.8 5.5 5.1-5.9 

  Latina 9.4 8.3-10.6 10.2 9.0-11.5 5.4 4.6-6.4 

  AI 7.6 5.6-10.0 9.1 6.8-11.8 3.1 1.9-4.9 

Cervical Female NHW 2.9 2.5-3.3 1.6 1.3-1.9 0.7 0.5-0.9 

  Latina 3.4 2.8-4.0 2.7 2.2-3.3 1.0 0.7-1.4 

    AI 2.2 1.3-3.6 1.9 1.0-3.3   

 



 
 
 
 
 

 

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Supplementary Table 2. Correlation between Cancer Incidence Rate and Socio-demographic Factors. 

   

Percent 

Urban 

Population 

Population 

Size in 2010 

Poverty 

Level 

Median 

Income 

High School 

Graduation 

Rate    

Percent 

Urban 

Population 

Population 

Size in 2010 

 Gender  rho P rho P Rho P rho P rho P 

Prostate Male All 0.475 0.07 0.775 0.001 -0.375 0.17 -0.004 0.99 -0.175 0.53 

  NHW 0.627 0.01 0.670 0.006 -0.524 0.045 0.265 0.34 0.057 0.84 

  Latino 0.604 0.02 0.593 0.02 -0.479 0.07 0.361 0.19 0.243 0.38 

Breast Female All 0.639 0.01 0.689 0.004 -0.533 0.04 0.314 0.25 -0.150 0.59 

  NHW 0.689 0.004 0.471 0.08 -0.223 0.42 0.132 0.64 0.311 0.26 

  Latino 0.518 0.048 0.425 0.11 -0.177 0.53 0.396 0.14 -0.161 0.57 

Lung Both All 0.004 0.99 -0.007 0.98 -0.572 0.03 0.264 0.34 -0.246 0.38 

  NHW 0.011 0.97 -0.157 0.58 -0.306 0.27 0.143 0.61 0.004 0.99 

  Latino -0.089 0.75 -0.229 0.41 -0.048 0.86 0.236 0.40 0.132 0.64 

 Male All -0.018 0.95 0.089 0.75 -0.552 0.03 0.229 0.41 -0.129 0.65 

  NHW 0.111 0.69 0.061 0.83 -0.259 0.35 0.057 0.84 0.093 0.74 

  Latino 0.032 0.91 -0.334 0.22 -0.268 0.33 0.329 0.23 0.011 0.97 

 Female All 0.282 0.31 0.375 0.17 -0.272 0.33 0.004 0.99 -0.336 0.22 

  NHW 0.104 0.71 0.000 1.00 -0.429 0.11 0.193 0.49 -0.157 0.58 

  Latina -0.020 0.95 -0.029 0.92 0.378 0.18 -0.156 0.59 0.209 0.47 

Colorectal Both All 0.257 0.36 0.071 0.80 -0.697 0.004 0.343 0.21 -0.039 0.89 

  NHW 0.236 0.40 0.039 0.89 -0.602 0.02 0.314 0.25 -0.043 0.88 

  Latino -0.068 0.81 -0.171 0.54 -0.088 0.76 0.143 0.61 -0.193 0.49 



 
 
 
 
 

 

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 Male All 0.354 0.20 0.218 0.44 -0.731 0.002 0.518 0.048 -0.032 0.91 

  NHW 0.336 0.22 0.271 0.33 -0.747 0.001 0.525 0.04 -0.125 0.66 

  Latino -0.229 0.41 -0.096 0.73 0.011 0.97 0.057 0.84 0.093 0.74 

 Female All 0.225 0.42 0.064 0.82 -0.379 0.16 0.057 0.84 -0.254 0.36 

  NHW 0.182 0.52 0.057 0.84 -0.172 0.54 -0.043 0.88 -0.229 0.41 

  Latina 0.021 0.94 -0.221 0.43 -0.200 0.47 0.282 0.31 -0.107 0.70 

Cervix Female All -0.239 0.39 -0.282 0.31 -0.082 0.77 -0.004 0.99 -0.139 0.62 

  NHW -0.615 0.03 -0.769 0.002 0.272 0.37 0.154 0.62 0.038 0.90 

  Latina -0.216 0.46 0.051 0.86 -0.123 0.67 -0.286 0.32 -0.095 0.75 

Statistically significant correlations are shown with bold. 

 

Supplementary Table 3. Barriers to Health Care, Cancer Screening Rate, and Cancer Risk Factors (Arizona Behavioral Risk Factor Surveillance System data) 

 AI Latino/Latina AA NHW 

 % 95% CI % 95% CI % 95% CI % 95% CI 

Barriers to Health Care         

   Living below 133% federal poverty line 11.1 6.4-15.8 13.8 12.0-15.6 9.9 6.0-13.7 2.8 2.3-3.2 

   Not having health insurance coverage 16.0 10.4-21.6 27.6 24.4-30.8 14.7 9.1-20.4 8.9 7.7-10.0 

   Could not afford health care 14.0 8.9-19.1 23.1 20.1-26.1 16.1 10.7-21.5 12.6 11.5-13.7 

   Usual source of health care 54.1 46.8-61.5 58.9 55.4-62.3 75.7 68.7-82.6 79.7 77.7-80.4 

Preventive Care Utilization         

   Had preventive check up in the last year 64.0 56.5-71.4 58.0 54.6-61.5 76.9 70.1-83.7 66.1 64.7-67.6 

Cancer Screening         



 
 
 
 
 

 

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   Ever had a Fecal Occult Blood Test 27.5 17.4-37.6 21.4 17.4-25.4 41.4 33.0-49.7 40.1 38.7-41.5 

   Ever had a Colonoscopy or sigmoidoscopy 34.6 24.9-44.3 54.6 49.4-59.8 70.6 62.3-78.9 71.5 70.1-72.9 

   Had a mammogram in the past year 62.4 49.9-75.0 57.6 52.1-63.2 62.1 51.6-72.6 55.9 54.0-57.9 

   Had a Pap Smear within the last 3 years 84.5 77.5-91.5 81.7 77.9-85.6 83.9 77.2-90.7 69.5 67.9-71.1 

   Ever had a PSA testa 19.2  53.8  77.2  80.5  

Cancer Risk Factors         

   Current smoker 12.0 7.8-16.2 14.0 11.5-16.5 16.2 10.9-21.6 17.5 16.3-18.8 

   Obesity (BMI>30) 44.9 37.4-52.5 33.8 30.5-37.1 36.8 29.6-44.0 26.4 25.1-27.7 

   Diabetes  14.8 10.2-19.3 10.4 7.7-13.8 10.7 7.7-13.8 9.9 9.2-10.6 

   High Blood Pressure 30.4 20.5-40.4 22.0 17.9-26.0 40.1 29.5-50.8 33.1 31.2-34.9 

2014 Arizona Behavioral Risk Factor Surveillance System Report (http://azdhs.gov/preparedness/public-health-statistics/behavioral-risk-factor-

surveillance/index.php#reports)   a Prostate Specific Antigen (PSA) screening test data is from 2010 Arizona Behavioral Risk Factor Surveillance System 

Report, and 95% CI was not reported. 

http://azdhs.gov/preparedness/public-health-statistics/behavioral-risk-factor-surveillance/index.php#reports
http://azdhs.gov/preparedness/public-health-statistics/behavioral-risk-factor-surveillance/index.php#reports

