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RESEARCH 

Potentially preventable cancers 

diagnosed among Alaska Native people 
 

Sarah H Nash1*, Diana G Redwood1 

1Alaska Native Epidemiology Center, Community Health Services, Alaska Native Tribal Health Consortium, 

Anchorage, AK 

*Corresponding author e-mail: shnash@anthc.org 
 

ABSTRACT 
Cancer is the leading cause of death among Alaska Native (AN) people, and the third leading cause of 

years of potential life lost. AN tribal health leaders and researchers want to understand the cancer 

burden attributable to modifiable risk factors among AN people to inform the design of cancer 

prevention strategies. To address this question, we estimated the population attributable risk (PAR) 

associated with modifiable cancer risk factors including obesity, smoking, physical inactivity, and alcohol 

use among AN people. PAR varied by cancer site and risk factor, and was highest for lung cancer and 

smoking, with an estimated 78.8% of cancers among males, and 69.8% among females attributable to 

this risk factor. A smaller, but still substantial proportion of cancers were associated with obesity (up to 

37% for endometrial cancer among females), physical inactivity (up to 18% for endometrial cancer 

among females), and alcohol use (up to 34% for breast cancers among heavy drinking females). Overall, 

we estimated that approximately 1500 cancers could be prevented over a 10-year period if these four 

risk factors were eliminated among AN people. This study demonstrates the importance of smoking as a 

primary prevention target to reduce the burden of cancer and other chronic diseases among AN 

people. However, it also indicates that obesity, physical activity, and alcohol use may account for a 

varying, but substantial proportion of cancers in this population. Given the high burden of cancer 

among AN people, a comprehensive approach to primary prevention is warranted.. 

 

KEYWORDS: Native American, population attributable risk, cancer prevention 

 

Citation: Nash SH and Redwood DG (2017).Potentially preventable cancers diagnosed among Alaska 

Native people. Cancer Health Disparities 2:e1-e15. doi:10.9777/chd.2018.10001

  



 
 
 
 
 

 

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INTRODUCTION 

Cancer is the leading cause of death among 

Alaska Native (AN) people, and the third leading 

cause of years of potential life lost (Alaska Native 

Epidemiology Center, 2017; Blake, 2016; Carmack, 

2015). In contrast to U.S. whites (USW), for whom 

cancer incidence and mortality rates have been 

significantly declining over the past 20+ years 

(Ryerson et al., 2016), rates remained fairly 

constant among Alaska Native people, resulting in 

a significant health disparity (Blake, 2016; Carmack, 

2015). Furthermore, disparities in incidence of 

several cancer sites exist between AN people and 

USW, including lung, colorectal, and 

nasopharyngeal cancers, which are 1.5, 2.3, and 

17.3 times higher among AN people than USW, 

respectively (Carmack, 2015; Kelly JJ et al., 2014). 

For these reasons, cancer is a leading concern 

among Alaska tribal health leaders and 

researchers, and the Alaska Native Tribal Health 

Consortium’s (ANTHC) Cancer Program has 

developed a Comprehensive Cancer Control Plan 

(CCCP) specifically for the Alaska Tribal Health 

System (ATHS) (2006). 

Reducing the burden of cancer among AN people 

may be achieved through a focus on cancer 

prevention. It has been estimated that upwards of 

50% of cancer deaths globally may be preventable 

(Colditz et al., 2006; Colditz and Wei, 2012), and a 

growing number of cancers are known to have risk 

factors that are potentially modifiable (Stein and 

Colditz, 2004). These include some of the leading 

cancer sites among Alaska Native people: female 

breast, lung, colorectal, and prostate cancers 

(Carmack, 2015).  Leading modifiable risk factors 

for cancer include tobacco use, alcohol use, diet, 

infectious diseases, obesity, and physical inactivity 

(Siegel et al., 2017; Stein and Colditz, 2004). Little is 

known about the burden of potentially 

preventable cancers among AN people. Yet, AN 

people do not meet national recommendations for 

many modifiable cancer risk factors, including 

tobacco use, overweight and obesity, and fruit and 

vegetable consumption (Lanier et al., 2012). There 

is a critical need to better understand modifiable 

risk factors for cancer among AN people, and the 

burden of potentially preventable cancers. The 

potential contribution of modifiable risk factors to 

cancer burden can be assessed using population 

attributable risk (PAR). This study analyzed the PAR 

associated with modifiable risk factors for cancer 

among AN people, including obesity, smoking, 

physical inactivity, and alcohol use.  

 

MATERIALS AND METHODS 

Study population 

American Indian and Alaska Native people (AI/AN) 

represent a diverse group indigenous to North 

America. The Alaska Department of Labor 

estimated that in 2014, 143,367 AI/AN people 

(alone or in combination) resided in Alaska, 

accounting for 19% of the total Alaska population 

(Alaska Department of Labor and Workforce 

Development, 2015). There are 229 federally 

recognized tribes in Alaska (American Congress of 

American Indians, 2017; Williams, 2009). 

The Alaska Tribal Health System (ATHS) is made 

up of over 14 regional tribal health organizations, 

which provide health care services, including 

health promotion and disease prevention 

programs, to all AI/AN beneficiaries living in 

Alaska. The Alaska Native Tribal Health Consortium 

(ANTHC), a consortium of regional tribal health 

organizations, provides statewide health services, 

and co-manages Alaska’s only tertiary tribal 

healthcare facility, the Alaska Native Medical 

Center (ANMC) located in Anchorage.  

Cancer Sites 

We estimated PAR for all cancer sites known to be 

associated with smoking, obesity, physical 

inactivity, or alcohol use. Smoking-related cancers 

were those determined by the 2014 Surgeon 

General’s report to be causally linked to smoking, 

and included acute myeloid leukemia (AML), as 

well as cancers of the bladder, colon and rectum, 

esophagus, kidney, larynx, liver, lung, oral cavity, 



 
 
 
 
 

 

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pancreas, stomach, and uterine cervix (Alberg et 

al., 2014). Obesity-related cancers were those 

determined by the World Cancer Research 

Fund/American Institute for Cancer Research to be 

associated with obesity (Wiseman, 2008), including 

cancers of the esophagus, stomach, colon and 

rectum, liver, gallbladder, pancreas, 

postmenopausal breast, kidney, advanced 

prostate, thyroid, and endometrium. Physical 

inactivity-related cancers were those determined 

by a recent systematic review and meta-analysis to 

be convincingly or probably associated with 

physical activity or inactivity (Friedenreich et al., 

2010), and included cancers of the colon, lung, 

prostate, breast, endometrium, and ovaries. Finally, 

alcohol-related cancers were those determined by 

a recent systematic review and meta-analysis to be 

statistically significantly associated with moderate, 

or heavy drinking (Bagnardi et al., 2015), including 

cancers of the colon and rectum, esophagus 

(squamous cell carcinoma (ICD-O histologies 

8070-8076) only), gallbladder, larynx, liver, lung, 

oral cavity, stomach, prostate, and breast. 

 

Data sources and definitions 

Prevalence of cancer risk factors among Alaska 

Native people was estimated using data from the 

Alaska Behavioral Risk Factor Surveillance Survey 

(BRFSS), collected by the Alaska Department of 

Health and Social Services, Division of Public 

Health, and the Centers for Disease Control and 

Prevention. Data reported are for the 5-year 

period 2011-2015, unless otherwise noted. 

Individuals were defined as current smokers if they 

reported having smoked more than 100 cigarettes 

in their lifetime, and also reported current 

smoking. Obesity was defined according to World 

Health Organization (WHO) guidelines as having a 

body mass index (BMI) ≥ 30 kg/m2. Physical 

inactivity was defined as not meeting the CDC-

recommended 150 minute/week of aerobic activity 

(Centers for Disease Control and Prevention, 

2008). Information on physical activity was 

available from the 2011, 2013, and 2015 BRFSS 

surveys only. Alcohol intake (g ethanol/day) was 

estimated as (average number of drinks/day*g 

ethanol/drink). We estimated that each drink 

contained 12.5 g ethanol (Bagnardi et al., 2015). 

We categorized moderate and heavy drinking as 

12.5 ≤ 50 g/d (4 drinks/d) and >50 g/d (4 

drinks/d), respectively, as per a recent review and 

meta-analysis (Bagnardi et al., 2015). 

Cancer case counts were from the National Cancer 

Institute Surveillance, Epidemiology, and End 

Results (SEER) Program’s Alaska Native Tumor 

Registry (ANTR). The ANTR is a population-based 

registry that records cancer information on AI/AN 

people who meet eligibility requirements for 

Indian Health Service benefits, who have been 

diagnosed with cancer in the state of Alaska, and 

who are Alaskan residents at the time of cancer 

diagnosis. As part of the ANTR’s standard 

surveillance process for collecting SEER data, cases 

were identified through a variety of sources, 

including: tumor registry and pathology files of 

ANMC and other Native and non-Native 

healthcare facilities throughout the state; linkage 

to the Alaska State Cancer Registry and the 

Washington State Cancer Registry; and death 

certificates (<1% cases). For this study we used 

data on the number of cancers diagnosed 

between January 1, 2006 and December 31, 2015. 

Classification of cancer site of origin, histologic cell 

type, behavior and grade coding followed the 

International Classification of Diseases for Oncology 

(ICD-O) third edition (2013). We included only 

invasive malignancies (ICD-O behavior code 3); 

benign and in situ tumors were not included in 

case counts (ICD-O behavior codes 0 and 2, 

respectively), nor were tumors of uncertain or 

unknown behavior (ICD-O behavior code 1). 

Menopausal status was not available through the 

registry; therefore, age at diagnosis (< 50y, ≥50 y) 

was used as a proxy to define post-menopausal 

breast cancer. Advanced prostate cancer was 

defined by having an AJCC stage group (7th 

edition; ref) of III or IV, or a Derived Summary 

Stage 2000 of “Distant.” 



 
 
 
 
 

 

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Table 1. Relative risk of cancer associated with each cancer site, and modifiable risk factor, used herein to estimate population attributable risk.a-d 

Cancer Site Smoking Obesity Physical Inactivity Moderate alcohol use Heavy alcohol use 

Male Female Male Female Male Female Male Female Male Female 

Acute Myeloid Leukemia 1.09 1.09 -- -- -- -- -- -- -- -- 

Bladder 3.14 3.14 -- -- -- -- -- -- -- -- 

Colorectal 1.19 1.28 -- -- -- -- 1.21 1.07 1.53 1.24 

Colon -- -- 1.45 1.12 1.32 1.32 -- -- -- -- 

Rectum -- -- 1.25 1.05 -- -- -- -- -- -- 

Esophagus 2.52 2.28 1.12 1.06 -- -- -- -- -- -- 

Esophageal SCC -- -- -- -- -- -- 2.23 2.23 4.95 4.95 

Gallbladder -- -- 1.54 1.75 -- -- -- -- 2.64 2.64 

Kidney and Renal Pelvis 1.59 1.35 1.59 1.91 -- -- -- -- -- -- 

Larynx 6.98 6.98 -- -- -- -- 1.44 1.44 2.65 2.65 

Liver 1.85 1.49 1.99 1.43 -- -- -- -- 2.07 2.7 

Lung 9.87 7.58 -- -- 1.43 1.43 -- -- -- -- 

Oral Cavity 3.43 3.43 -- -- -- -- 1.83 1.83 5.13 5.13 

Pancreas 1.63 1.73 1.45 1.28 -- -- -- -- -- -- 

Stomach 1.74 1.45 1.11 1 -- -- -- -- -- -- 

Thyroid -- -- 1.14 1.26 -- -- -- -- -- -- 

Male only                     

Prostate -- -- -- -- 1.25 -- -- -- -- -- 

Advanced prostate -- -- 1.15 -- -- -- -- -- -- -- 

Female only                     

Breast -- -- -- -- -- 1.33 -- 1.23 -- 1.61 

Postmenopausal breast -- -- -- 1.16 -- -- -- -- -- -- 

Endometrium -- -- -- 2.54 -- 1.43 -- -- -- -- 

Ovarian -- -- -- -- -- 1.23 -- -- -- -- 



 
 
 
 
 

 

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Uterine cervix -- 1.83 -- -- -- -- -- -- -- -- 
a
Relative risk estimates for smoking taken from: Gandini et al Int J Cancer 2008: 122;155-164. Botteri et al JAMA 2008:300;2765-2778. 

b
Relative risk estimates for obesity 

taken from Cheragi et al PLoS One 2012:7;e51446. Xue et al Eur J Cancer Prev 2016: 26, 94-105. Jenabi et al Pub Health 2015:129;872-880. 
c
Relative risk estimates for 

physical inactivity modified from Friedenreich et al Eur J Cancer 2010:46;2593-2604. 
d
Relative risk estimates for alcohol use (moderate and heavy) taken from Bagnardi 

et al Br J Cancer 2015:112;580-593 

 

 

Table 2. Prevalence of modifiable risk factors for cancer among Alaska Native people, Alaska Behavioral Risk Factor Surveillance System, 2011-2015. 

 

 Obesity Smoking Physical Inactivity Current drinking 

Current drinking 

(yes) 

Moderate (1-4 

drinks/day) 

Heavy (>4 

drinks/day) 

Average drinks/ day 

Total 34.8 (33.0, 36.6) 37.7 (35.9, 39.5) 50.9 (47.4, 54.3) 42.4 (40.2, 44.7) 8.9 (7.7, 10.3) 10.4 (9.1, 11.8) 0.41 (0.36, 0.46) 

Sex        

Male 31.6 (29.2, 34.0) 40.2 (37.6, 42.9) 49.8 (44.9, 54.8) 44.8 (41.5, 48.2) 12.0 (9.9, 14.4) 11.6 (9.8, 13.8) 0.56 (0.47, 0.66) 

Female 38.4 (35.7, 41.1) 35.1 (32.6, 37.7) 51.9 (47.0, 56.7) 40.0 (36.9, 43.1) 5.8 (4.6, 7.3) 9.1 (7.4, 11.1) 0.25 (0.21, 0.29) 

Age (yr)        

18-34 26.3 (23.4, 29.4) 42.2 (38.9, 45.5) 44.8 (38.8, 5.9) 45.3 (41.3, 49.5) 10.2 (7.9, 13.1) 11.1 (8.7, 14.0) 0.42 (0.33, 0.5) 

35-49 42.4 (38.8, 46.0) 40.9 (37.4, 44.5) 53.5 (46.9, 60.1) 48.4 (44.1, 52.8) 10.7 (8.4, 13.4) 9.3 (7.2, 11.9) 0.54 (0.43, 0.66) 

50-64 39.3 (36.0, 42.7) 35.9 (32.7, 39.2) 54.0 (47.8, 60.1) 37.6 (33.8, 41.5) 8.1 (6.0, 10.8) 8.6 (6.8, 10.8) 0.35 (0.27, 0.44) 

65+ 38.4 (33.7, 43.4) 17.0 (13.9, 20.6) 58.5 (47.8, 68.4) 30.4 (23.9, 37.9) 3.7 (2.5, 5.5) 12.0 (8.4, 16.8) 0.2 (0.14, 0.25) 

 

 

 



 
 
 
 
 

 

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Table 3. Population attributable risk (PAR) percent and estimated preventable cases (EPC) of cancers classified as associated with tobacco, obesity, and 

physical inactivity.  

 Tobacco Obesity Physical inactivity 

 Male Female Male Female Male Female 

  PAR EPC PAR EPC PAR EPC PAR EPC PAR EPC PAR EPC 

Acute Myeloid Leukemia 3.6 0.7 3.1 0.4 -- -- -- -- -- -- -- -- 

Bladder 47.3 16.1 42.9 7.7 -- -- -- -- -- -- -- -- 

Colorectal 7.3 25.2 8.9 30.9 -- -- -- -- -- -- -- -- 

Colon -- -- -- -- 12.6 42.9 4.4 15.1 13.6 29.8 14.1 35.9 

Rectum -- -- -- -- 6.9 8.5 1.8 1.7 -- -- -- -- 

Esophagus 38.9 16 31 6.8 3.5 1.4 2.2 0.5 -- -- -- -- 

Gallbladder -- -- -- -- 13.9 0.4 22.2 1.8 -- -- -- -- 

Kidney and Renal Pelvis 19.8 22.0 10.9 10.0 15.0 16.7 25.7 23.4 -- -- -- -- 

Larynx 71.5 17.9 67.7 3.4 -- -- -- -- -- -- -- -- 

Liver 26.3 15.3 14.7 4.0 22.9 12.8 14 3.5 -- -- -- -- 

Lung 78.8 280.7 69.8 201.7 -- -- -- -- 17.5 62.6 18.1 52.6 

Oral Cavity 50.5 44.5 46 26.7 -- -- -- -- -- -- -- -- 

Pancreas 20.9 11.1 20.3 10.8 11.9 6.3 9.6 5.1 -- -- -- -- 

Stomach 23.7 24.9 13.6 9.8 3.2 3.4 -- -- -- -- -- -- 

Thyroid -- -- -- -- 4.0 1.1 9.0 7.8 -- -- -- -- 

Male only                         

Prostate -- -- -- -- -- -- -- -- 11.1 22.7 -- -- 

Advanced prostate -- -- -- -- 4.3 1.6 -- -- -- -- -- -- 

Female only                         

Breast -- -- -- -- -- -- -- -- -- -- 14.7 94.0 

Postmenopausal breast -- -- -- -- -- -- 5.7 26.9 -- -- -- -- 

Endometrium -- -- -- -- -- -- 36.9 29.9 -- -- 18.1 14.6 



 
 
 
 
 

 

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Ovarian -- -- -- -- -- -- -- -- -- -- 10.9 5.5 

Uterine cervix -- -- 22.6 13.3 -- -- -- -- -- -- -- -- 

Total   474.4   325.5   95.1   115.7   115.1   202.6 
a
EPC for a 10-year period, calculated using the number of cancers diagnosed among AN people for the 10-year period from 2006-2015.  

 

 

Table 4. Population attributable risk (PAR) percent and estimated preventable cases (EPC) of cancers classified as associated with moderate and heavy 

alcohol use.  

  Moderate drinking Heavy drinking 

  Males Females Males Females 

Cancer site PAR EPC PAR EPC PAR EPC PAR EPC 

Colorectal 2.5 8.4 0.4 1.4 5.8 19.8 2.1 7.4 

Esophageal SCC 12.9 3.5 6.7 0.5 31.4 8.5 26.4 2.1 

Gallbladder -- -- -- -- 16.0 1.3 13 1.8 

Larynx 5.0 1.3 2.5 0.1 16.1 4 13.1 0.7 

Liver -- -- -- -- 11.0 6.2 8.9 2.2 

Lung -- -- -- -- 1.7 6.1 1.3 3.9 

Oral cavity 9.1 8 4.6 2.7 32.4 28.5 27.3 15.8 

Stomach -- -- -- -- 2.4 2.5 1.9 1.4 

Female only                 

Breast -- -- 1.3 8.4 -- -- 5.3 33.5 

Total   21.2  13.1  76.9  68.8 
a
EPC for a 10-year period, calculated using the number of cancers diagnosed among AN people for the 10-year period from 2006-2015.  



 
 
 
 
 

 

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Statistical methods 

Prevalence estimates of cancer risk factors are 

given with 95% confidence intervals (CI), to 

account for the BRFSS sampling strategy and 

weighting. Differences in prevalence of cancer risk 

factors by sex and age categories (18-34, 35-49, 

50-64, and 65+ years) were assumed to be 

statistically significant where 95% CI did not 

overlap. 

Population attributable risk was estimated 

using Levin’s formula: 

 

PAR = [Ppop x (RR-1)]/[Ppop x (RR-1) +1] 

 

where Ppop is the prevalence of the risk factor 

among Alaska Native people and RR is the relative 

risk of cancer associated with each risk factor 

(Levin, 1953). RR estimates specific to Alaska Native 

people were unavailable; therefore we used sex-

specific estimates (where available), generated 

from meta analyses conducted among other 

US/European populations (Bagnardi et al., 2015; 

Botteri et al., 2008; Cheraghi et al., 2012; 

Friedenreich et al., 2010; Gandini et al., 2008; 

Jenabi and Poorolajal, 2015; Xue et al., 2017). 

Relative risk estimates used for calculations are 

given in Table 1. The estimated preventable 

cancers (EPC) for each risk factor was estimated by 

multiplying the PAR for that risk factor/cancer by 

the number of cancers at that site diagnosed 

among AN people over the most recent 10-year 

period: 2006-2015. A longer duration (i.e., 10-year 

period vs 5-year period examined for risk factor 

prevalence) was chosen to reduce the impact of 

case number fluctuations on our estimates of EPC, 

given small AN population numbers and case 

counts. Institutional Review Board Review and 

approval were not required for the current study 

because both BRFSS and SEER Program data are 

publically available, and all patient data were de-

identified. Appropriate tribal review and approval 

was obtained for publication of this study. 

RESULTS 

Prevalence of modifiable cancer risk factors 

among Alaska Native People 

Self-reported BRFSS prevalence of obesity, current 

smoking, physical inactivity, and current drinking 

(light/heavy/moderate) among AN people is given 

in Table 2. Over a third of AN people reported 

being obese; prevalence of obesity was higher 

among females (38.4%) than males (31.6%). 

Obesity prevalence was lowest in those aged 18-

34 years, but was similar between all other age 

categories. Overall, smoking prevalence was 

almost 38%; current smoking was slightly higher 

among males (40.2%) than females (35.1%). 

Smoking prevalence was similar among those 

aged 18-34, 35-49, and 50-64; however, it was 

substantially lower among those aged 65 years 

and older. Overall, prevalence of physical inactivity 

was high, with over half (50.9%) of AN people 

reporting they did not meet the guidelines; this 

proportion was similar in strata of sex and age. 

Finally, over one third (42.4%) of AN people 

reported consuming at least one alcoholic drink/ 

month; a far smaller proportion reported 

moderate (8.9%) and heavy (10.45) drinking, 

respectively. The proportion of moderate and 

heavy drinkers was slightly higher among males, 

relative to females; yet there was no consistent 

pattern evident within strata of age.   

 

Potentially preventable cancers among Alaska 

Native people 

PAR and EPC for obesity-, smoking-, and physical 

inactivity-related cancers are given in Table 3. The 

number and proportion of potentially preventable 

cancers varied by risk factor and cancer site. The 

highest PAR was observed for smoking: over 70% 

of lung cancers (78.8% among males, 69.8% 

among females), and a similar proportion of 



 
 
 
 
 

 

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laryngeal cancers (71.5% male, 67.7% female) 

could be potentially preventable with elimination 

of this risk factor. Overall, we estimated that 

approximately 800 cancers could be prevented in 

Alaska over a 10-year period if smoking were 

eliminated among AN people. 

Obesity and physical inactivity represented a 

smaller, but still substantial, number of potentially 

preventable cancers (Table 3). Again, PAR varied 

by cancer site, but was highest for obesity and liver 

cancer (22.9% among males, 14.0% among 

females), and physical inactivity and lung cancer 

(17.5% among males, 18.1% among females). Both 

obesity and physical inactivity showed a 

particularly strong prevention potential for female 

cancers: PAR for endometrial cancer was 36.9% for 

obesity, and 18.1% for physical inactivity. Similarly, 

PAR associated with physical inactivity was 14.7% 

for breast cancer, and 10.9% for ovarian cancer. 

We estimated that approximately 210 cancers 

could be prevented among Alaska Native people 

by eliminating obesity and 317 by eliminating 

physical inactivity over a 10-year period.  

Finally, we examined the prevention potential 

associated with both moderate and heavy drinking 

for alcohol-related cancers; these data are given in 

Table 4. Overall, both PAR and EPC were higher 

for heavy drinking than for moderate drinking; 

total EPC over a 10-year period for these risk 

factors was 146 and 34, respectively. As with the 

other risk factors that we examined, PAR varied by 

site. For heavy drinking, the highest PAR was 

observed for female breast cancer (33.5%), 

esophageal squamous cell carcinoma (31.4% 

males, 26.4% females), and cancers of the oral 

cavity (32.4% males, 27.3% females). In addition, a 

smaller, but still substantial proportion of cancers 

of the gallbladder, larynx and liver could also be 

prevented with the elimination of heavy drinking 

among AN people. Similar to heavy drinking, the 

highest PAR for moderate drinking was observed 

for esophageal squamous cell carcinoma (12.9% 

males, 6.7% females), and cancers of the oral 

cavity (9.1% males, 4.6% females). We estimated 

that eliminating moderate and heavy drinking may 

prevent up to 34 and 146 cancers among Alaska 

Native people, respectively, over a 10-year period.  

DISCUSSION 

The burden of cancer among AN people is high 

(Carmack, 2015; Kelly JJ et al., 2014). Yet, our 

results suggest that a potentially substantial 

proportion of these cancers may be prevented if 

exposure to four key modifiable risk factors: 

smoking, obesity, physical inactivity, and alcohol 

use, could be eliminated in this population. PAR 

was highest for several smoking-related cancer 

sites; the high prevalence of smoking among AN 

people and importance of tobacco cessation and 

prevention efforts has been previously recognized 

(Patten et al., 2007; Patten et al., 2008; Renner et 

al., 2004; Smith et al., 2010; State of Alaska 

Tobacco Prevention and Control Program, 2015; 

Wolsko et al., 2009). However, these results also 

suggest the importance of recognizing and 

addressing other modifiable risk factors in a 

comprehensive approach to the primary 

prevention of cancer. Such an approach is also 

likely to have additional benefit to AN people, as 

obesity, physical inactivity and alcohol use have 

been linked to other outcomes of concern, 

including diabetes, heart disease, chronic liver 

disease, and unintentional injury (Murphy et al., 

1997; Murphy et al., 1995). While we recognize that 

reducing or eliminating exposure to these risk 

factors will provide a challenge to the Alaska Tribal 

Health System, this study provides data to help 

prioritize primary prevention efforts for the 

greatest reduction in AN cancer burden. These 

data reinforce the Alaska Tribal Health System’s 

focus on tobacco use prevention and smoking 

cessation, and emphasize the importance of 

encouraging other healthy behaviors as well, 

including being physically active, maintaining a 

healthy weight, and low consumption of alcohol. 

These data suggest that the greatest cancer 

prevention potential for the AN population is to 

reduce smoking. Of particular note, between 43% 



 
 
 
 
 

 

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and 79% of cancers of the lung, larynx, oral cavity, 

and bladder could be prevented with elimination 

of this risk factor. This is at the high end of the 

range of values observed across other, non-Native 

populations (Whiteman and Wilson, 2016), likely 

due to the high prevalence of smoking among AN 

people (Lanier et al., 2012; Redwood et al., 2010). 

In this study, prevalence of smoking was twice as 

high as has been reported for U.S. (2012) or Alaska 

whites (Alaska Department of Health and Social 

Services, 2016), and several rural Alaska boroughs 

(counties) with a high proportion of Alaska Native 

residents have among the highest smoking 

prevalence in the nation (e.g., 42% in the Northern 

Region, 2014 (Dwyer-Lindgren et al., 2014)). 

Furthermore in 2014, 15% of AN people reported 

using smokeless tobacco (Alaska Department of 

Health and Social Services, 2016), which has been 

linked to oral cancer, esophageal cancer, and 

pancreatic cancer, as well as heart and gum 

disease (Boffetta et al., 2008; Organization and 

Cancer, 2007). Our estimates of PAR did not 

include smokeless tobacco use; including this 

would likely inflate the estimates of PAR given 

here. Importantly, the high prevalence of smoking 

is likely a key contributor to several cancer 

disparities among AN people. For example, 

incidence of and mortality from lung cancer is 1.5 

times higher among AN people, relative to U.S. 

whites (Carmack, 2015). Several state- and tribally-

managed tobacco use prevention programs exist 

to encourage and support AN people who wish to 

quit smoking, including the Alaska Quitline and 

ANTHC’s Tobacco Prevention and Control 

Program, which provides tobacco cessation 

services to AN people statewide, as well as training 

for community tobacco treatment specialists.  

In addition to smoking, these data demonstrate 

that obesity and physical inactivity may also be 

associated with a substantial proportion of cancer 

among AN people (e.g., up to 37% for obesity and 

endometrial cancer); however, these results must 

be considered in context of what we know about 

obesity and physical activity among AN people. 

For example, the associations of obesity with 

chronic disease risk factors has been shown to be 

modified by intake of n-3 polyunsaturated fatty 

acids (Lemas et al., 2013; Makhoul et al., 2011; 

Vaughan et al., 2015), which are high in many AN 

traditional foods (Bersamin et al., 2008; Bersamin 

et al., 2006; Bersamin et al., 2007). Thus, it is 

possible that AN traditional subsistence activities, 

including consumption of AN traditional foods, 

may alleviate some of the cancer risk associated 

with obesity. Furthermore, AN people may 

experience physical activity differently than 

recommended by national guidelines, which could 

also modify the PAR estimates presented herein. 

Studies have shown that while few AN people may 

reach guideline amounts of moderate and 

vigorous physical activity, a potentially larger 

proportion may engage in lower intensity 

traditional activities such as harvesting wild berries 

and greens, and fishing for potentially longer 

periods of time (Redwood et al., 2009). An 

increasing body of literature supports the 

importance of increasing physical activity levels 

and avoiding sedentary behaviors (Arem et al., 

2014; Arem et al., 2015; Howard et al., 2015; 

Matthews et al., 2012; Matthews et al., 2015; Moore 

et al., 2016), perhaps to include the AN (Yup’ik) 

concept of “keeping busy” (Hopkins et al., 2007), 

as a key component of disease risk reduction.  

Several ANTHC programs support healthy 

behaviors around food and physical activity 

among Alaska Native people. Recently, ANTHC 

partnered with the State of Alaska’s Play Every Day 

childhood obesity prevention campaign to create 

culturally-appropriate public service 

announcements for AN youth  (Alaska Department 

of Health and Social (Services, 2017). In addition, 

ANTHC activities such as “Store Outside your 

Door” which promotes knowledge and use of AN 

traditional wild foods from around the state, and 

“Alaskan Plants as Foods and Medicine” promote 

healthy eating and traditional food consumption 

for all AN people. While these activities are not 

explicitly geared towards cancer prevention, our 



 
 
 
 
 

 

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RESEARCH 

results suggest that reducing obesity and 

increasing physical activity may be beneficial in 

reducing cancer risk among AN people, and 

support the continued investment in, and 

evaluation of, such programs.  

Alcohol use is also an important consideration for 

cancer prevention among AN people. These data 

demonstrate a lower prevalence of occasional 

drinking among AN people than has been 

reported for U.S. whites (Henley et al., 2014). 

Patterns of alcohol use may differ among AN 

people because of the cultural and political 

landscape around its consumption. Many rural AN 

communities are “dry” or “damp,” meaning that 

they do not permit the consumption or sale of 

alcohol, respectively. We observed a high rate of 

abstinence among AN people, with over 65% of 

AN people reporting they do not currently drink 

(Table 2). Yet, our data also show that a substantial 

proportion of potentially preventable cancers may 

be related to alcohol use (e.g., up to 33.5% of 

breast cancers, among heavy drinking females). In 

addition to the substantial cancer prevention 

potential presented herein, elimination of excess 

alcohol use could have immediate implications for 

reducing other leading causes of AN mortality, 

including unintentional injury and suicide (Blake, 

2016). While alcohol use is recognized as a cancer-

causing agent (Baan et al., 2007), strategies and 

activities to reduce its use are not always included 

in tribal and state Comprehensive Cancer Control 

Plans (Henley et al., 2014), including the Alaska 

Tribal Health System Comprehensive Cancer 

Control Plan (2011-2017) (2006). Future iterations 

of the plan should include strategies that address 

the cancer prevention potential associated with 

reduced exposure to this risk factor at a 

population level.  

Finally, these data can be compared to recent 

reports on PAR from across the U.S. A recent 

analysis by Islami and colleagues (Islami et al., 

2017) estimated that up to 42% of incident cancers 

in the U.S. could be attributed to major modifiable 

cancer risk factors. As in the present study, 

smoking was a leading cause of both preventable 

cancers and cancer deaths: the authors estimated 

that approximately 80% of lung cancer cases were 

attributable to cigarette smoking. This is 

remarkably similar to our findings, given that 

prevalence of smoking and tobacco use is known 

to be substantially higher among Alaska Native 

people (e.g. 35-40% in the present study, versus 

approximately 15% nationwide (Jamal, 2016)). 

Nevertheless, differences can be observed: for 

example, approximately 20% of colon and rectal 

cancer cases (combined) among males may be 

attributed to obesity among AN men, compared 

to only 4.8% of colorectal cancer cases among 

U.S. males nationwide (Islami et al., 2017). Yet, 

despite differences in the methodology and cancer 

sites examined in the two studies, both estimate 

that a substantial proportion of cancers could be 

attributable to obesity, physical inactivity, and 

alcohol use. Similar findings have been reported 

for other populations globally (Arnold et al., 2015; 

Arriaga et al., 2017a; Parkin et al., 2011; Whiteman 

and Wilson, 2016). This growing body of research 

emphasizes need for dissemination and 

implementation of known cancer preventive 

measures. Our study further supports the need to 

understand population attributable risk associated 

with modifiable cancer risk factors in minority 

populations across the U.S., in order to be able to 

provide appropriate, population-specific 

prevention programs.   

This is the first study to examine the burden of 

potentially preventable cancers among AN people 

using the population attributable risk metric, and 

provides a new way of looking at potential causes 

of cancer among this underserved population. 

Furthermore, these data may provide a novel and 

effective way of communicating risk to AN tribal 

health leaders and community members; future 

research should address the acceptability and 

accessibility of this metric for cancer risk 

communication among AN people. Yet this study 

also has several limitations that should be 

acknowledged. First, we were unable to use AN-



 
 
 
 
 

 

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RESEARCH 

specific relative risk estimates in our calculations; 

associations of risk factors with cancer outcomes 

may differ among AN people from the 

predominantly U.S./European populations on 

which the risk estimate meta-analyses used in this 

study were based. It is also assumed that risk 

factors for cancer among AN people mirror those 

observed in other populations; however, further 

research is necessary to explore whether there are 

AN specific risk or protective factors that might be 

the focus of successful primary prevention 

programs, and the strength of these associations. 

For example, the importance of Helicobacter pylori 

in the etiology of stomach cancer (Keck et al., 

2014) and colorectal cancer (Lee et al., 2016; Qing 

et al., 2016; Sonnenberg and Genta, 2013; 

Zumkeller et al., 2006), or HBV/HCV in the etiology 

of liver cancer among AN people (Connelly et al., 

2016) has been previously demonstrated. 

Furthermore, we acknowledge that our use of 

Levin’s formula may have resulted in 

overestimation of the PAR, as this method does 

not account for effect modification, confounding, 

or competing risks (Arriaga et al., 2017b; Flegal, 

2014; Flegal et al., 2004; Flegal et al., 2007).  In 

particular, obesity and physical inactivity are likely 

to be highly interlinked. In addition, we note that 

PAR was calculated using BRFSS prevalence data 

from 2011-2015, and EPC using ANTR case count 

data from 2006-2015. Thus, our calculations do 

not account for any potential lag between 

exposure to the risk factors examined, and 

incidence of cancer. Changes in both risk factor 

prevalence, and cancer case counts, over time, 

would result in changes to the results presented 

herein. Finally, we note that BRFSS data are self-

reported, and may not represent “true” risk factor 

exposure among the AN population. Importantly, 

potentially sensitive exposures such as alcohol may 

be underreported. Despite these limitations, these 

data provide a novel view of cancer among Alaska 

Native people, and provide data that may be 

useful to tribal health leaders and public health 

practitioners alike. 

This study examined the population attributable 

risk for several leading modifiable risk factors for 

cancer among AN people. While smoking was the 

primary leading modifiable risk factor, a smaller, 

but still substantial proportion of cancers may be 

linked to other risk factors including obesity, 

physical inactivity and alcohol use. Our results 

demonstrate the need for a comprehensive 

approach to primary cancer prevention among AN 

people. Eliminating tobacco use, increasing 

healthy diet and physical activity, and moderating 

alcohol use would help substantially decrease the 

cancer burden and resultant health disparities 

experienced by AN people. By enhancing 

evidence-based prevention efforts in these areas, 

cancer morbidity and mortality would be reduced. 

Acknowledgements 

Dr. Nash and the Alaska Native Tumor Registry are 

supported by the NCI’s Surveillance, Epidemiology 

and End Results Program, NCI contract number 

HHSN26120130010I, Task Order HHSN26100005. 

Dr. Redwood is supported by the Centers for 

Disease Control and Prevention, Building Public 

Health Infrastructure for Alaska Native People 

Component A, Grant # 1 NU58DP006379-01-00. 

 

Conflict of interest statement 
The author has declared that no competing or 

conflict of interests exists. The funders had no role 

in study design, writing of the manuscript and 

decision to publish.    

 

Authors’ contributions 
SHN: conceptualization, formal analysis, 

methodology, project administration, writing - 

original draft, writing - review and editing. DGR: 

writing- review and editing.  

 

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