USC/Norris Comprehensive Cancer Center Keck School of Medicine of the University of Southern California

L o s A n g e l e s C a n c e r S u r v e i l l a n c e P r o g r a m USC/Norris Comprehensive Cancer Center Keck School of Medicine of the University of Southern California

Dennis Deapen, DrPH and Myles Cockburn, PhD 23 Los Angeles Cancer Surveillance Program USC/Norris Comprehensive Cancer Center The Keck School of Medicine of the University of Southern California 154 Alcazar Street, CHP24 Los Angeles, California 933 Suggested citation: Deapen D, Cockburn M (eds). Cancer in Los Angeles County: Trends by Race/Ethnicity, 1976-2. Los Angeles Cancer Surveillance Program, University of Southern California, 23. Copyright 23 by the University of Southern California All rights reserved This document, or parts thereof, may not be reproduced in any form without citation.

Contributing editors........................................................1 Executive summary.........................................................2 Preface...................................................................4 Introduction...............................................................6 Historical background of the CSP............................................6 The diverse population of Los Angeles County.................................6 The changing population of Los Angeles County...............................8 How cancer is registered..................................................9 Use of CSP data for research...............................................9 The importance of investigating time trends..................................1 Protection of confidentiality..............................................11 Materials and methods.....................................................12 Distribution of all cancers combined by race/ethnicity.............................14 Distribution of cancers by anatomic site, sex and race/ethnicity.....................16 The most common cancer sites among males.................................16 The most common cancer sites among females................................16 Trends in the most common cancers by sex and race/ethnicity......................2 Site-specific trends by sex and race/ethnicity....................................29 Brain and other nervous system............................................3 Breast.................................................................32 Cervix.................................................................34 Colon/rectum...........................................................36 Esophagus.............................................................38 Hodgkin s disease.......................................................4 Kaposi s sarcoma........................................................42 Kidney and renal pelvis...................................................44 Larynx................................................................46 Leukemia..............................................................48 Liver..................................................................5 Lung..................................................................52 Melanoma.............................................................54 Multiple myeloma.......................................................56 Nasopharynx...........................................................58 Non-Hodgkin s lymphoma.................................................6 Oral cavity.............................................................62 Ovary.................................................................64 Pancreas...............................................................66 Prostate...............................................................68 Stomach...............................................................7 Testis.................................................................72 Thyroid................................................................74 Urinary bladder.........................................................76 Uterus................................................................78 APPENDIX A: Detailed methods...............................................8 Determination of race/ethnicity of patients...................................8 Population denominators.................................................8 Technical terms.........................................................81 Calculation of rates and trends in rates......................................82 Adoption of the year 2 standard population...............................83 APPENDIX B: Number of observed cases by sex, race/ethnicity and site, and statistical test of linear trends.............................................84 APPENDIX C: Methods used in the generation of special site-specific graphs...........97 APPENDIX D: Denominators used in the calculation of five year rates................98 References..............................................................1 C O N T E N T S Los Angeles Cancer Surveillance Program

CONTRIBUTING EDITORS Leslie Bernstein, PhD Professor Victoria Cortessis, PhD Assistant Professor Wendy Cozen, DO Assistant Professor Frank Gilliland, MD, PhD Professor Ann Hamilton, PhD Assistant Professor Lihua Liu, PhD Research Scientist Thomas Mack, MD, MPH Professor Wendy Mack, PhD Associate Professor Susan Preston-Martin, PhD Professor CONTRIBUTING EDITORS Ronald Ross, MD Professor and Chairman Anna Wu, PhD Professor Mimi Yu, PhD Professor Department of Preventive Medicine The Keck School of Medicine of the University of Southern California 1 Los Angeles Cancer Surveillance Program

EXECUTIVE SUMMARY EXECUTIVE SUMMARY The Los Angeles Cancer Surveillance Program (CSP) serves as a resource to generate new hypotheses regarding cancer causes, to monitor trends and patterns of cancer incidence, and to identify population subgroups at high risk of cancer. Monitoring rates of cancer can provide a report card on how well cancer prevention programs are working. Government officials and policymakers use trends in cancer rates to determine funding for treatment and related social services. Los Angeles County is the most populous and ethnically diverse county in the U.S. The substantial differences among rates of most cancers between men and women and various race/ethnic groups provide clues for a better understanding of cancer. Highlights of cancer incidence trends in Los Angeles County from 1976 to 2 include: Cancer incidence varied greatly by race/ethnicity. For fourteen cancer sites one race/ethnic group had at least three times greater incidence than another race/ethnic group. For all cancers combined, black men had the highest cancer rate followed in order by non-latino white, Latino white, Japanese, Filipino, Chinese and Korean men. Among women, non-latino whites had the highest overall rates of cancer, followed in order by blacks, Latino whites, Japanese, Filipino, Chinese and Korean women. Breast cancer was the most common cancer among females regardless of race/ethnicity and has increased rapidly among Japanese and Filipinas, but not among other race/ethnic groups. Cervical cancer rates declined among all race/ethnic groups, presumably due to successful screening interventions, but the rate of decline was small in Koreans and Filipinas, possibly due to limited access to screening. 2 Los Angeles Cancer Surveillance Program Endometrial (uterus) cancer rates declined among all women in the 197s and 198s, but most notably among non-latina whites. However, there have been no further declines in any race/ethnic group. Prostate cancer was the most common male cancer, except among Korean men. Prostate cancer rates reached a peak following the introduction of the prostate-specific antigen (PSA) test. Lung cancer rates initially increased among men and then declined in blacks and non-latino whites, but have not yet done so for other race/ethnic groups. Lung cancer rates in women increased for all race/ethnic groups.

Melanoma rates among non-latino whites increased so rapidly in the past 25 years that they are now among the top five cancers for both males and females. Some of this increase is likely due to increased surveillance. Stomach cancer rates declined steadily among non-latino whites, blacks, Latino whites and Japanese, but increased rapidly among Filipinos, Koreans and Chinese. This may be due to differing immigration patterns, because stomach cancer rates are higher in the Philippines, Korea and China than in Los Angeles. Colorectal cancer rates, traditionally lower among Filipinos and Koreans, are increasing among these groups, as well as among Japanese. Rates for blacks and Latino and non-latino whites are declining. Testis cancer rates increased rapidly among Latino and non-latino whites but testis cancer remained a rare disease among other race/ethnic groups. Thyroid cancer rates increased rapidly among Filipinos for unknown reasons, yet remained steady in all other race/ethnic groups over the past 25 years. Rates of Kaposi s sarcoma initially rose dramatically with progression of the AIDS epidemic, but have now declined. The initial increase did not occur in Japanese and Filipinos. 3 Los Angeles Cancer Surveillance Program EXECUTIVE SUMMARY

P R E F A C E PREFACE Most Californians have been touched by the effect of illness, disability or death because of cancer either personally or among family and friends. Medical science continues to battle this scourge with research on causes, treatment and outcomes. High quality cancer registries are central to those efforts. In each U.S. state, cancer registries identify newly diagnosed cancer patients to track trends and create opportunities for research. The Los Angeles Cancer Surveillance Program (CSP) is the population-based cancer registry for Los Angeles County, California. Since 1972, the CSP has collected and analyzed information on all new cancers diagnosed among residents of the County. Over the past thirty years, with the participation of physicians, hospitals and cancer patients, this information has produced major contributions to the knowledge and understanding of cancer and its causes, its treatment and effects on the lives of cancer patients and their families. Health-care providers and researchers in Los Angeles County, as well as nationally and internationally, frequently use the information to help control cancer. The CSP is a member of the statewide population-based cancer surveillance system, the California Cancer Registry (CCR). It is also part of the National Cancer Institute s Surveillance, Epidemiology, and End Results (SEER) program. The CSP is administered by the Keck School of Medicine of the University of Southern California (USC) and the USC/Norris Comprehensive Cancer Center. With the large and diverse population of Los Angeles County, the CSP has served as a resource for many epidemiological studies of cancer. 4 Los Angeles Cancer Surveillance Program Over the past thirty years, with the participation of physicians, hospitals and cancer patients, this information has produced major contributions to the knowledge and understanding of cancer and its causes, treatment and impact This volume provides physicians, researchers, public health officials and the public with high quality data documenting the trends of many different types of cancer in Los Angeles County over twenty-five years. These data illustrate considerable differences in cancer incidence between men and women and among various racial/ethnic groups in a way not previously available to our community. These differences not only identify the types of persons at greater and lesser risk of each cancer but also offer intriguing clues that may lead to better understanding and prevention of cancer. This report was prepared by the following CSP researchers: Myles Cockburn, PhD, epidemiologist; Dennis Deapen, DrPH, director; Lihua Liu, PhD, demographer; Juanjuan Zhang, MS, programmer; Yaping Wang, MS, programmer; Leslie Bernstein, PhD, Scientific Director; Ronald K. Ross, MD, Medical

Director, and the contributing editors listed on page 1. As with all reports produced by the CSP, great appreciation goes to the hospital cancer registrars, the CSP field technicians and other CSP staff whose dedication and hard work provide the foundation for this report. ACKNOWLEDGMENTS Cancer incidence data used in this report have been collected by the CSP under Subcontract 1873 supported by the California Department of Health Services as part of its statewide cancer reporting program, mandated by Health and Safety Code Section 21 and 211.3. Support has also been provided by the Division of Cancer Prevention and Control, National Cancer Institute, U.S. Department of Health and Human Services, under the assigned contract N1-PC- 671 and P1-NCI-CA1754. The production of this report was funded by Centers for Disease Control and Prevention contract U75-CCU91677-6, the California Cancer Registry through California Public Health Institute subcontract 11249 and the USC/Norris Comprehensive Cancer Center. PREFACE Dennis Deapen Myles Cockburn 5 Los Angeles Cancer Surveillance Program

I N T R O D U C T I O N INTRODUCTION HISTORICAL BACKGROUND OF THE CSP The Los Angeles Cancer Surveillance Program (CSP) is the population-based cancer registry for Los Angeles County. It identifies and obtains information on all new cancer diagnoses made in Los Angeles County. The CSP was organized in 197 and operates within the administrative structure of the Keck School of Medicine of the University of Southern California (USC). The CSP was initially a component of a laboratory-based viral oncology program and, as such, was part of the National Viral Cancer Program. It was developed with the voluntary cooperation of hospitals and other institutions, clinics and medical laboratories equipped to diagnose cancer in Los Angeles County. By 1972, the registry reflected cancer occurrence for the entire county, and complete incidence data are available from that year onward. To date, the CSP database contains more than 1.2 million records and about 35, incident cancers are added annually. Since 1981, the CSP has been the State-designated legal agent of Los Angeles County for collecting information on all new cancer cases among county residents for monitoring cancer incidence patterns and trends. In 1987, it became the regional registry for Los Angeles County for the then new California Cancer Registry. The CSP is one of 1 such regional registries providing, as a group, statewide coverage. In September 1992, the CSP joined the National Cancer Institute s Surveillance, Epidemiology and End Results (SEER) program. This consortium of 18 population-based SEER registries provides the federal government with ongoing surveillance of cancer incidence and survival in the U.S. 6 Los Angeles Cancer Surveillance Program The CSP has a bibliography of more than 5 publications contributed to scientific journals The CSP is one of the most productive cancer registries in the world in terms of scientific contributions toward understanding the demographic patterns and the etiology of specific cancers. The CSP has a bibliography of more than 5 publications in scientific journals 1. The registry supports a large ongoing body of research funded mainly by the U.S. National Cancer Institute, other cancer research organizations and the State of California. THE DIVERSE POPULATION OF LOS ANGELES COUNTY According to the 2 Census, with 9.5 million people, 3.4% of the total U.S. population resides in Los Angeles County, and 12% of the country s Hispanic residents live in the county. A high proportion of the U.S. totals of Asian and Pacific Islander subgroups live in the county, including 17.7% of Thais, 17.3% of Koreans, 16.7% of Indonesians, 16.4% of Cambodians, 14.8% of Sri Lankans, 14.1% of Filipinos, 14.1% of Samoans, 14% of Japanese, and 13.5%

of Chinese 2. More than one-third (35.8%) of Los Angeles County residents are foreign-born; 36.7% of them (over 1.2 million) entered this country during 199-2 3. More than half (54.5%) of the population five years of age or older in Los Angeles County speak a language other than English 2. Hispanics in Los Angeles County are not only a large but also a diverse group. The 2 Census shows that 44.6% of the residents of Los Angeles County (i.e., 4,242,213 individuals) self-reported as Hispanic or Latino. Among them, 3,41,974 (71.7%) are Mexican, 37,862 (.9%) Puerto Rican, 38,664 (.9%) Cuban, 372,777 (8.8%) Central American, 74,75 (1.8%) South American, and 674,451 (15.9%) other Hispanic or Latino 2. In the 2 census, as in previous censuses, a higher proportion of Los Angeles County Hispanics identified themselves as other in the race category than in the U.S. as a whole (52.3% compared to 42.2%) 2. The population of Los Angeles is racially, ethnically and religiously extremely diverse I N T R O D U C T I O N Non-Hispanic whites in Los Angeles County also have highly diverse origins. The population of European origin includes large numbers of persons from Britain and from all parts of Europe. In the past 25 years Los Angeles County has experienced a large influx of immigrants from Iran, Lebanon and the former U.S.S.R. The Armenian community is estimated to number more than 2,. Approximately 6, individuals of Arabic descent live in Los Angeles County 3. Every numerically important religious group in the U.S. is also represented with sizable populations in Los Angeles; these include Seventh-day Adventists and Mormons whose cancer patterns are of particular interest to cancer epidemiologists. The county also has the largest Jewish community in the world outside of Israel, numbering more than 5,. Demographic diversity is only one aspect of a spectrum of differences that make Los Angeles County a unique location for a population-based cancer registry. It is characterized by marked geographic diversity that affects ambient air pollution patterns. Ambient air pollution is an important public health problem throughout the county but, nonetheless, pollution indices vary considerably from season to season and by geographic regions of the county. The county includes many beach communities, as well as those in the San Fernando and San Gabriel valleys, communities that lie inland of mountain ranges. Also, the population of Los Angeles County varies widely in socioeconomic and sociocultural characteristics. Occupation and industry data reflect the diversity one would expect of a large urban metropolis. Because of the changes in the urban and rural criteria for the 2 census, the rural population in Los Angeles County increased dramatically to approximately 1.8 million in 2. 7 Los Angeles Cancer Surveillance Program

I N T R O D U C T I O N THE CHANGING POPULATION OF LOS ANGELES COUNTY One reason Los Angeles County is an excellent place to perform cancer surveillance is that it has an enormous diversity of racial/ethnic groups. In the 25 years covered by this monograph, the population proportions of each racial/ethnic group have changed dramatically. For example, the Latino white population has increased so rapidly that in the 2 Census, Latino whites were the largest minority in Los Angeles, which for the first time ever, had no majority racial/ethnic group. The next largest racial/ethnic group is non-latino whites, previously the majority in Los Angeles. The black population has remained fairly constant over the past 25 TRENDS IN POPULATION IN LOS ANGELES COUNTY (1976-2), BY RACE/ETHNICITY (MALES) 25 2 years, accounting for just 15 under one-half million 1 persons. The Asian populations have rapidly 5 increased since the late 197s, particularly the 1 Korean, Filipino and Chinese populations 5 while the Japanese population has grown much less by comparison. 1 POPULATION (IN 's) 1976 1981 1986 1991 1996 2 YEAR 8 Los Angeles Cancer Surveillance Program POPULATION (IN 's) 25 2 15 1 5 1 5 1 TRENDS IN POPULATION IN LOS ANGELES COUNTY (1976-2), BY RACE/ETHNICITY (FEMALES) 1976 1981 1986 1991 1996 2 YEAR Latino white Black Non-Latino white Chinese Japanese Filipino Korean Other Latino white Black Non-Latino white Chinese Japanese Filipino Korean Other

HOW CANCER IS REGISTERED Under the California model of reporting, a passive cancer surveillance system has been implemented statewide in which hospitals and other facilities where cancer is diagnosed or treated bear the responsibility for identifying and reporting cancer cases to the local registry within six months after the patient s diagnosis or treatment. Our data serve as a resource to generate new hypotheses regarding the causes of specific cancer and means of To provide complete demographic and treatment information on each new cancer occurring among the residents of Los Angeles County and to guarantee compliance with reporting requirements, the CSP combines elements of an active and preventing them a passive surveillance system. For active surveillance, each of the medical facilities in which microscopic verification of cancer occurs is visited periodically by a CSP field technician who systematically screens all hematology and pathology reports to identify all previously unreported cancer diagnoses. The State-mandated passive surveillance system requires each hospital or other reporting facility to complete a full report known as an abstract, including stage and treatment information, on every cancer case seen at the facility. All completed abstracts are linked by the CSP to the pathology reports obtained under active surveillance to assure that one abstract is completed for each histologically verified cancer diagnosis. In addition, any previously unrecognized cancer diagnoses among Los Angeles County residents, identified as a result of searching computerized death records, are traced back to patient records in hospitals or other facilities so that data can be abstracted, when possible, in a similar way to data found using pathology reports. I N T R O D U C T I O N USE OF CSP DATA FOR RESEARCH The CSP data serve as a descriptive epidemiological resource to generate new hypotheses regarding specific cancer sites or histologic subtypes, monitor descriptive trends and patterns of cancer incidence, and identify demographic subgroups at high risk of cancer. A high priority is always placed on exploring demographic patterns and trends in cancer incidence among the racially and ethnically diverse population of Los Angeles County. As a service to the community, the CSP provides data on cancer occurrence specific to subareas of Los Angeles County. The CSP receives occasional requests from community physicians or from the county and state health departments seeking assistance in investigating perceived cancer risks from environmental exposures. The CSP can generate rosters of cancer patients who are eligible for case-control studies. In such studies, additional information about each patient is gathered by personal interview, record 9 Los Angeles Cancer Surveillance Program

I N T R O D U C T I O N abstraction or by the collection and analysis of biological specimens. The data are then compared with similar information gathered from people without cancer (controls) who have been chosen to represent the population from which the cancer patients came. The CSP data can also be used for analytic studies of the cohort design. In such studies, a large roster of Los Angeles County residents who have had in common a particular exposure, lifestyle or other characteristic of public health interest are matched to the CSP registry of patients to see whether or not an excess of cancer has appeared among them. THE IMPORTANCE OF INVESTIGATING TIME TRENDS To keep an eye on cancer rates Monitoring cancer rates provides clues about what causes cancer. When we observe a change in the rate of cancer that seems to follow a change in some environmental exposure, we consider the possibility of a link between the exposure and cancer. For example, increasing lung cancer rates followed the introduction and increasing popularity of cigarettes and smoking early last century. To know whether cancer control efforts are working We also monitor rates of cancer to provide a report card on how well cancer prevention programs work. We generally expect that a successful intervention program, such as the introduction of smoke free dining and advertising campaigns aimed at preventing teenagers from starting to smoke, should be followed by a decline in lung and other smoking related cancer rates. In fact, from the early 199s onward we have seen such a decline in lung and other smoking-related cancers in Los Angeles County. 1 Los Angeles Cancer Surveillance Program Monitoring cancer rates provides clues about what causes cancer To decide what resources are required to fight cancer Because cancer is such an important health problem and is costly in terms of treatment and social costs such as loss of work time and quality of life, it is important to have a clear idea of the changing burden of cancer on society. Government officials and policymakers use trends in cancer rates to determine funding for treatment and related social services, and to establish priorities for supporting effective research into the causes and prevention of cancer and the development of treatments.

To see the effect of changes in cancer screening and detection methods Many things can cause a change in cancer rates, including changes in the distribution of the factors that cause the disease, changes in our ability to prevent or detect cancer early, changes in the population mix, changes in diagnostic criteria to define a type of cancer, and even simple random variation. Prostate cancer rates increased rapidly after the introduction of the prostate-specific antigen test which provided better diagnostic ability than previous tests. This was not because prostate cancer was truly becoming more common, but it was simply because we found prostate cancer cases that previously would not have been diagnosed. To make cancer a disease of the past Keeping an eye on cancer rates provides clues about the causes of cancer, how successful we are at preventing cancer, and where we should focus our efforts in the future to make cancer a disease of the past. Confidentiality procedures at the CSP are rigidly formulated and maintained I N T R O D U C T I O N PROTECTION OF CONFIDENTIALITY Confidentiality procedures at the CSP are rigidly formulated and maintained. All employees of the CSP sign a confidentiality pledge after being advised of the necessity for maintaining strict confidentiality of patient information and instructed in routines to assure this. Any records containing identifying information are transported to the CSP in locked carrying cases and are stored in locked filing cabinets at the CSP. Confidentiality of computerized data is assured by highly restricted access. All reports and summaries produced for distribution by the CSP, such as those presented here are in statistical form without any personal identifiers. All individual studies using confidential information obtained from the registry are individually reviewed by the USC Institutional Review (Human Subjects) Board as is the registry itself on a regular basis. For studies from outside investigators, review and approval by a federally approved institutional review board is required. 11 Los Angeles Cancer Surveillance Program

MATERIALS AND METHODS MATERIALS AND METHODS INCIDENCE DATA Cancer incidence data contained in this report are based on new cases of cancer that were first diagnosed among Los Angeles County residents from January 1, 1976 to December 31, 2 and were reported to the CSP as of November 22. Although incidence data were available from 1972 onwards, we have chosen to use only the most recent 25 years of data, so that we can generate five equal five year time periods for the calculation of rates. Cancers are distinguished by whether they are invasive (those that have spread beyond the layer of cells where it first developed and is growing into surrounding healthy tissue) or in situ (early cancer that has not invaded surrounding cells or tissue). In this report we only consider invasive cancers, with the following three exceptions. Because of the difficulty in interpreting the language used by pathologists to describe the extent of invasion of bladder cancers 4, in situ bladder cancers are combined with invasive bladder cancers, and are included in the data for all invasive cancers combined. In situ brain cancers are included for all years. For breast cancers, we included only invasive cancers in the overall trend presentation, but we provide a separate trend graph showing in situ cancers as they reflect the effect of mammography on trends in rates (see page 32). We present cancer incidence rates separately for race/ethnicity groups defined as follows: we split the white population of Los Angeles County into Latino and non-latino whites, determined by whether or not their surname matches a listing of Spanish surnames. The remaining population is separated into blacks (African-Americans), Chinese, Japanese, Filipinos and Koreans. We describe how race/ethnicity is defined and obtained for cancer patients and the Los Angeles population in Appendix A. 12 Los Angeles Cancer Surveillance Program In this report we only consider invasive cancers A total of 841,151 cancers diagnosed among Los Angeles County residents between January 1, 1976 and December 31, 2 were reported to the CSP as of November, 22. Of these cancers, 744,144 (88.5%) were invasive malignancies, 77,834 (9.3%) were in situ malignancies and 19,173 (2.3%) were of uncertain or unknown behavior. We have excluded 9,344 (1.3%) malignancies with unknown race/ethnicity from our analyses. Exclusion of these patients from the racial/ethnic group to which they belonged will cause race/ethnicity-specific rates to be slightly underestimated. Cases of unknown, ill-defined or rare sites, a total of 56,821 patients, were included in the counts and rates for all sites combined but do not appear in any of the site-specific analyses. The exclusion of cancers classified as unknown or ill defined will result in a slight underestimation of the rates of the specific cancers that were the true sites.

CAUTIONS IN INTERPRETATION Cancer incidence data in this report are based on cases of primary cancer which were reported to the CSP as of November 22. Case reporting for 2 was estimated to be at least 95 percent complete as of that date. In the future a small number of additional cases will continue to be reported for 2 and for earlier years. This may have a minor effect on the final incidence rates for this period. The reliability of race/ethnicity-specific rates depends on the accuracy of classification race/ethnicity classification of the cancer patients and of the Los Angeles County population. Some small part of the variations in race/ethnicity-specific rates may reflect misclassification rather than a true difference in cancer risk. The county population estimates are based on self-identification at the time of the 2 census. Race/ethnicity information for cancer cases is based primarily on information contained in the patient s medical record. This information may be based on self-identification by the patient, on assumptions made by an admission clerk or other medical personnel, or on an inference made using race/ethnicity of parents, birthplace, maiden name or last name. The reporting of race/ethnicity in any system may be influenced by the racial/ethnic distribution of the local population, local interpretation of data collection guidelines, and other factors. The use of surname lists partially compensates for misclassification of some racial/ethnic groups. Finally, special caution should be used when interpreting the meaning of the rates that are based on only a few cases. Rates based on small numbers are statistically unstable. For that reason, we have adopted the convention of only graphing points that are based on at least 2 cases. In the tables of case counts provided in Appendix B, we have not provided any count that is less than three cases, denoting these with an asterisk. This is to avoid the possibility of identifying an individual. The reliability of race/ethnicityspecific rates depends on the accuracy of race/ethnicity MATERIALS AND METHODS 13 Los Angeles Cancer Surveillance Program

DISTRIBUTION OF ALL CANCERS COMBINED 14 Los Angeles Cancer Surveillance Program Among males, blacks had the highest overall cancer rates DISTRIBUTION OF ALL CANCERS COMBINED BY RACE/ETHNICITY When considering the overall rate of cancer by race/ethnicity, it is important to remember that cancers occurring at different sites are in fact very different diseases. Therefore, little practical information about the causes of cancers can be obtained from comparing the rate of all cancers combined among groups. We provide the comparison of average annual age-adjusted rates for all cancer sites combined simply to demonstrate the importance of cancer as a whole in each racial/ethnic group compared to others and to provide overall counts of cancer cases for each racial/ethnic group. Black men had the highest overall rates of cancer between 1976 and 2, approximately twice the rates of cancer among each of the Asian groups. Non- Latino white men also had very high rates of cancer compared to the Asian groups. Among the Asian groups, Japanese men had the highest overall rates of cancer. Latino white men had slightly higher rates of all cancers combined than Asian groups, but substantially lower than black and non-latino white men. NUMBER OF CANCER CASES OCCURRING BETWEEN 1976 AND 2 FOR EACH RACIAL/ETHNIC GROUP Males Females Race/ethnicity Number Number Latino White 44,846 48,324 Black 44,616 38,65 Non-Latino White 256,78 265,27 Chinese 5,359 5,81 Japanese 5,39 5,28 Filipino 5,14 5,561 Korean 2,7 2,775 In contrast, non-latina white women had the highest rates of all cancers combined, and rates among black women were intermediate between non-latina white women and Japanese and Latino white women. Korean women had the lowest overall rates of cancer.

AVERAGE ANNUAL AGE-ADJUSTED INCIDENCE RATES PER 1, PERSONS, OF ALL CANCERS COMBINED 1976-2, FOR EACH MAJOR RACIAL/ETHNIC GROUP AVERAGE ANNUAL AGE-ADJUSTED RATE (PER 1,) AVERAGE ANNUAL AGE-ADJUSTED RATE (PER 1,) 7 6 5 4 3 2 1 7 6 5 4 3 2 1 364.4 Latino white 261.3 Latino white 66.9 Black non-latino white 355.4 Black 517.3 49.8 non-latino white MALES 276. Chinese FEMALES 26.6 Chinese 339.3 Japanese 259.7 Japanese 286. 273.9 Filipino 219.5 Filipino Korean 183.3 Korean Among females, non-latino whites had the highest overall cancer rates DISTRIBUTION OF ALL CANCERS COMBINED 15 Los Angeles Cancer Surveillance Program

DISTRIBUTION OF CANCERS BY ANATOMIC SITE 16 Los Angeles Cancer Surveillance Program DISTRIBUTION OF CANCERS BY ANATOMIC SITE, SEX AND RACE/ETHNICITY In this section we provide an overview of the distribution of cancers from 1976 to 2 in Los Angeles County according to the site on the body where they occur (anatomic site). In the following pages we present figures for men and women for Latino whites, blacks, non- Latino whites, Chinese, Japanese, Koreans and Filipinos. The numbers presented are percentages of all cancers combined, so they do not sum to 1%, because only the most common anatomic sites are included in the figures. THE MOST COMMON CANCER SITES AMONG MALES Among males in each race/ethnicity group except Koreans, prostate cancer was the most common cancer, but it ranged in frequency from 7.5% of all male Colon & Rectum 1.3% Stomach 4.8% Pancreas 2.5% NHL 5.6% Leukemia 5.% Melanoma 1.1% Oral 2.6% Lung 1.6% Prostate 23.6% Urinary Bladder 2.6% Colon & Rectum 1.8% Stomach 3.3% Pancreas 2.6% NHL 2.6% Leukemia 2.2% Melanoma.4% Oral 3.5% Lung 2.3% Prostate 3.8% Urinary Bladder 2.2% Latino white Black 1.4% 1.1% 26.1% 6.% 8.2% 3.4% 2.5% 5.3% 1.1% 5.7% 1.%.5% 1.7% 28.8% 12.1% 14.2% 2.6% 3.4% 3.3% 4.6% 4.6% 1.4% Melanoma Oral Breast Lung Colon & Rectum Stomach Pancreas Ovary Cervix Uterus Urinary Bladder 3.7% 3.6% Melanoma Oral Breast Lung Colon & Rectum Stomach Pancreas Ovary Cervix Uterus Urinary Bladder 2.4% 2.3% NHL Leukemia NHL Leukemia

cancers among Koreans, to 3.8% of all male cancers among blacks. Prostate cancer was only the fourth most common cancer among Korean men, after stomach, lung and colorectal cancers. Lung cancer was the second most common cancer among men, except among the Japanese, where colorectal cancer was more predominant. Among men, regardless of race/ethnicity, cancers of the stomach, lung, colon and rectum and prostate cancer accounted for about 5% of all cancers. Leukemia and lymphomas (including non- Hodgkin s lymphoma (NHL)) accounted for less than 1% of all cancers, except among non-latino white men where slightly more than 1% of cancers were leukemia or lymphomas. While melanoma accounted for almost 5% of cancers among non- Latino white men, among all other racial/ethnic groups melanoma accounted for 1% or less of all cancers. Colon & Rectum 12.5% Stomach 2.4% Pancreas 2.4% NHL 4.1% Leukemia 3.1% Melanoma 4.4% Oral 3.6% Lung 16.9% Prostate 24.9% Urinary Bladder 5.1% Colon & Rectum 16.9% Stomach 6.7% Pancreas 2.4% NHL 3.7% Leukemia 2.9% Melanoma.2% Oral 1.8% Lung 17.1% Prostate 15.8% Urinary Bladder 3.2% Non-Latino white Chinese 3.3% 2.% 3.% 12.1% 12.6% 1.5% 2.5% 4.3% 2.1% 7.1% 1.8%.3% 1.2% 26.7% 1.5% 14.2% 5.3% 2.2% 5.2% 4.4% 4.1% 1.3% Melanoma Oral Breast Lung Colon & Rectum Stomach Pancreas Ovary Cervix Uterus Urinary Bladder 3.3% 2.4% Melanoma Oral Breast Lung Colon & Rectum Stomach Pancreas Ovary Cervix Uterus Urinary Bladder 3.3% 2.2% NHL Leukemia NHL Leukemia DISTRIBUTION OF CANCERS BY ANATOMIC SITE 17 Los Angeles Cancer Surveillance Program

DISTRIBUTION OF CANCERS BY ANATOMIC SITE 18 Los Angeles Cancer Surveillance Program THE MOST COMMON CANCER SITES AMONG FEMALES Breast cancer was the most common cancer among women regardless of their race/ethnicity, ranging from 19% of all cancers among Korean women, to 38% of all cancers among Filipina women. In contrast to men, colorectal cancer, not lung cancer, was usually the second most common cancer among women. Exceptions were Korean women who more frequently had stomach cancer than colorectal cancer, and among Latina white women who more commonly had cervical than colorectal cancer. Melanoma was a more common cancer among non-latina white women than other racial/ethnic groups, but still accounted only for 3.3% of their cancers. Colon & Rectum 2.8% Stomach 1.1% Pancreas 3.2% NHL 4.1% Leukemia 2.8% Melanoma.5% Oral 1.7% Lung 13.6% Prostate 23.3% Urinary Bladder 3.% Colon & Rectum 12.5% Stomach 18.4% Pancreas 3.2% NHL 3.1% Leukemia 2.6% Melanoma.2% Oral 2.4% Lung 17.7% Prostate 7.5% Urinary Bladder 2.9% Japanese Korean.6% 1.2% 31.5% 7.2% 18.% 6.4% 3.4% 4.7% 2.4% Melanoma Oral Breast Lung Colon & Rectum Stomach Pancreas Ovary Cervix 5.8% Uterus 1.6% Urinary Bladder.5%.8% 19.% 7.6% 11.8% 12.3% 2.9% 4.3% 9.7% 3.1% 1.8% Melanoma Oral Breast Lung Colon & Rectum Stomach Pancreas Ovary Cervix 2.5% Uterus.9% Urinary Bladder 2.3% 2.2% NHL Leukemia NHL Leukemia

Colon & Rectum 11.3% Stomach 3.% Pancreas 2.1% NHL 5.1% Leukemia 4.% Melanoma.4% Oral 1.6% Lung 17.9% Prostate 28.9% Urinary Bladder 2.% Filipino.2% 1.3% 38.% 6.3% 8.% 1.6% 1.9% 5.3% 4.8% 6.3%.5% Melanoma Oral Breast Lung Colon & Rectum Stomach Pancreas Ovary Cervix Uterus Urinary Bladder 4.% 2.3% NHL Leukemia DISTRIBUTION OF CANCERS BY ANATOMIC SITE 19 Los Angeles Cancer Surveillance Program

TRENDS IN THE MOST COMMON CANCERS 2 Los Angeles Cancer Surveillance Program TRENDS IN THE MOST COMMON CANCERS BY SEX AND RACE/ETHNICITY In this section we present trends for the most common cancer sites from 1976 to 2. In the previous section, we looked at the proportion of cases allotted to each anatomic site over the entire 25-year period. Here we look at age-adjusted incidence rates to account for the different age structures of the racial/ethnic groups so that racial/ethnic groups can be appropriately compared to one another. Details on the calculation of age-adjusted rates, and more on the importance of comparing age-adjusted rates, are provided in Appendix A. All rates are calculated using the same standard population (the U.S. 2 standard population). There have been significant changes in race/ethnicity of the Los Angeles population since 1976, which have been accompanied by the aging of some populations at a more rapid rate than others, which makes it even more important to age-adjust rates. Here we present only the top five cancer sites for each racial/ethnic group. The top five position is based on the incidence rate in the last time period (1996-2), so not all cancers shown were always top five cancers for example, melanoma in non-latino whites has only in the past five years become one of the top five most common cancers in 1976 it ranked sixth among non-latino white men, and eighth among non-latina white women. AGE-ADJUSTED RATE (PER 1,) 175 14 15 7 35 TRENDS IN THE TOP FIVE CANCERS AMONG LATINO WHITE MALES: AGE-ADJUSTED INCIDENCE RATES, LOS ANGELES COUNTY (1976-2) 1976-8 1981-85 1986-9 1991-95 1996-2 Prostate Colon and Rectum Lung Non-Hodgkin's Lymphomas Stomach

AGE-ADJUSTED RATE (PER 1,) AGE-ADJUSTED RATE (PER 1,) 3 24 18 12 6 225 18 135 9 45 TRENDS IN THE TOP FIVE CANCERS AMONG BLACK MALES: AGE-ADJUSTED INCIDENCE RATES, LOS ANGELES COUNTY (1976-2) 1976-8 1981-85 1986-9 1991-95 1996-2 Prostate Lung Colon and Rectum Stomach Non-Hodgkin's Lymphomas TRENDS IN THE TOP FIVE CANCERS AMONG NON-LATINO WHITE MALES: AGE-ADJUSTED INCIDENCE RATES, LOS ANGELES COUNTY (1976-2) Prostate 1976-8 1981-85 1986-9 1991-95 1996-2 Lung Colon and Rectum Melanoma Non-Hodgkin's Lymphomas TRENDS IN THE MOST COMMON CANCERS 21 Los Angeles Cancer Surveillance Program

TRENDS IN THE MOST COMMON CANCERS 22 Los Angeles Cancer Surveillance Program AGE-ADJUSTED RATE (PER 1,) 1 8 6 4 2 TRENDS IN THE TOP FIVE CANCERS AMONG CHINESE MALES: AGE-ADJUSTED INCIDENCE RATES, LOS ANGELES COUNTY (1976-2) 1976-8 1981-85 1986-9 1991-95 1996-2 Prostate Colon and Rectum Lung Liver Stomach The notable trends in each of the cancer sites presented in these graphs are outlined in more detail in later sections. Here we are simply contrasting the differences in the trends in the most common cancers across the racial/ethnic groups, to highlight which cancers are most common for each of the different racial/ethnic groups and how those most common cancers have changed over time. Cancers of the prostate, lung and colon/rectum have all behaved very similarly among Latino white, black and non-latino white men, with prostate cancer increasing (and showing a peak in the early 199s) and lung and colorectal cancers declining overall. However, among Chinese and Korean men, all these highest-frequency cancers increased markedly. While prostate cancers in Japanese and Filipino men appear to have followed the trends experienced by Latino white, black and non-latino white men, lung and colorectal did not. Those cancers increased rapidly, particularly among Filipinos. Chinese, Japanese, Korean and Filipino men all experienced very high rates of stomach cancer in the 197s, which declined first for Japanese, and more recently for Koreans. Stomach cancer has declined rapidly and consistently for Latino white and black men and was not a high frequency cancer at all among non-latino white men. Liver cancer was frequent and increased rapidly among Chinese, Filipino and Korean men, but it was not a frequent cancer for other racial/ethnic groups.

AGE-ADJUSTED RATE (PER 1,) AGE-ADJUSTED RATE (PER 1,) 15 12 9 6 3 15 12 9 6 3 TRENDS IN THE TOP FIVE CANCERS AMONG JAPANESE MALES: AGE-ADJUSTED INCIDENCE RATES, LOS ANGELES COUNTY (1976-2) 1976-8 1981-85 1986-9 1991-95 1996-2 Prostate Colon and Rectum Lung Stomach Non-Hodgkin's Lymphomas TRENDS IN THE TOP FIVE CANCERS AMONG FILIPINO MALES: AGE-ADJUSTED INCIDENCE RATES, LOS ANGELES COUNTY (1976-2) Prostate Lung 1976-8 1981-85 1986-9 1991-95 1996-2 Colon and Rectum Non-Hodgkin's Lymphomas Liver TRENDS IN THE MOST COMMON CANCERS 23 Los Angeles Cancer Surveillance Program

TRENDS IN THE MOST COMMON CANCERS 24 Los Angeles Cancer Surveillance Program AGE-ADJUSTED RATE (PER 1,) 75 6 45 3 15 TRENDS IN THE TOP FIVE CANCERS AMONG KOREAN MALES: AGE-ADJUSTED INCIDENCE RATES, LOS ANGELES COUNTY (1976-2) 1976-8 1981-85 1986-9 1991-95 1996-2 Lung Stomach Colon and Rectum Prostate Breast cancer was the predominant cancer among women, increasing in all groups from 1976 to 2, especially among Japanese and Filipina women. Lung cancer rates also increased for all racial/ethnic groups, more so among blacks than other groups. While colorectal cancers were either unchanged or declined among Latino white, black and non-latino white women, rates of colorectal cancer among Japanese, Chinese, Filipina and Korean women increased markedly. Stomach cancer was a frequent disease among Chinese, Japanese and Korean women, but increased only among Chinese and Koreans. Filipina women had high and increasing rates of thyroid cancer, while no other group did. Liver

AGE-ADJUSTED RATE (PER 1,) AGE-ADJUSTED RATE (PER 1,) 1 8 6 4 2 15 12 9 6 3 TRENDS IN THE TOP FIVE CANCERS AMONG LATINO WHITE FEMALES: AGE-ADJUSTED INCIDENCE RATES, LOS ANGELES COUNTY (1976-2) TRENDS IN THE TOP FIVE CANCERS AMONG BLACK FEMALES: AGE-ADJUSTED INCIDENCE RATES, LOS ANGELES COUNTY (1976-2) 1976-8 1981-85 1986-9 1991-95 1996-2 Breast 1976-8 1981-85 1986-9 1991-95 1996-2 Colon and Rectum Lung and Bronchus Cervix Uterus Breast Colon and Rectum Lung Uterus Pancreas TRENDS IN THE MOST COMMON CANCERS 25 Los Angeles Cancer Surveillance Program

TRENDS IN THE MOST COMMON CANCERS 26 Los Angeles Cancer Surveillance Program AGE-ADJUSTED RATE (PER 1,) AGE-ADJUSTED RATE (PER 1,) 175 14 15 7 35 75 6 45 3 15 TRENDS IN THE TOP FIVE CANCERS AMONG NON-LATINO WHITE FEMALES: AGE-ADJUSTED INCIDENCE RATES, LOS ANGELES COUNTY (1976-2) 1976-8 1981-85 1986-9 1991-95 1996-2 Breast Lung Colon and Rectum Uterus Melanoma TRENDS IN THE TOP FIVE CANCERS AMONG CHINESE FEMALES: AGE-ADJUSTED INCIDENCE RATES, LOS ANGELES COUNTY (1976-2) Breast 1976-8 1981-85 1986-9 1991-95 1996-2 Colon and Rectum Lung Stomach Ovary

AGE-ADJUSTED RATE (PER 1,) AGE-ADJUSTED RATE (PER 1,) 125 1 75 5 25 125 1 75 5 25 TRENDS IN THE TOP FIVE CANCERS AMONG JAPANESE FEMALES: AGE-ADJUSTED INCIDENCE RATES, LOS ANGELES COUNTY (1976-2) TRENDS IN THE TOP FIVE CANCERS AMONG FILIPINO FEMALES: AGE-ADJUSTED INCIDENCE RATES, LOS ANGELES COUNTY (1976-2) 1976-8 1981-85 1986-9 1991-95 1996-2 Breast 1976-8 1981-85 1986-9 1991-95 1996-2 Colon and Rectum Lung Uterus Stomach Breast Colon and Rectum Lung Thyroid Uterus TRENDS IN THE MOST COMMON CANCERS 27 Los Angeles Cancer Surveillance Program

TRENDS IN THE MOST COMMON CANCERS 28 Los Angeles Cancer Surveillance Program AGE-ADJUSTED RATE (PER 1,) 75 6 45 3 15 TRENDS IN THE TOP FIVE CANCERS AMONG KOREAN FEMALES: AGE-ADJUSTED INCIDENCE RATES, LOS ANGELES COUNTY (1976-2) 1976-8 1981-85 1986-9 1991-95 1996-2 Breast Colon and Rectum Stomach Lung Uterus

SITE-SPECIFIC TRENDS BY SEX AND RACE/ETHNICITY In this section we present trends in cancer incidence rates in Los Angeles County between 1976 and 2, for major locations of the body (groupings of anatomic sites), and for Kaposi s sarcoma, a cancer that is found at many anatomic sites, but is of interest in its own right (see page 42 for details). Each of these cancers is described in one set of facing pages. For each cancer site we provide a description of worldwide trends in the cancer of interest, along with a brief description of what is known about causes of the cancer. A short description of the trends in Los Angeles between 1976 and 2 is presented for that cancer site, along with a summary of the reasons, where they are known, for the observed trends. For each cancer site we provide two graphs, one for males and one for females (except for gender-specific cancers, such as cervix and prostate). Each graph contains one line describing the trend in cancer incidence for each of the 7 major racial/ethnic groups: Latino whites, blacks, non- Latino whites, Chinese, Japanese, Filipinos and Koreans. However, where a point on the graph would be based on fewer than 2 cases, the point and the line joining it to other points are omitted. We use this approach so that the lines we plot are based on sufficient numbers of cases about which we can draw firm conclusions. The numbers of cases graphed in each time period, and statistical measures of the significance of any apparent trends in rates are provided in Appendix B. Where special graphs are presented that focus on a subtype of the cancer site (for example, adenocarcinoma of the lung), the distinctions used to arrive at those special groupings can be found in Appendix C. SITE-SPECIFIC TRENDS BY SEX AND RACE/ETHNICITY 29 Los Angeles Cancer Surveillance Program

BRAIN AND OTHER NERVOUS SYSTEM Susan Preston-Martin, PhD SITE-SPECIFIC TRENDS BY SEX AND RACE/ETHNICITY 3 Los Angeles Cancer Surveillance Program CAUSES AND WORLDWIDE TRENDS Cancers of the brain and other nervous system are relatively rare cancers that account for approximately 2% of all cancers in the U.S. Almost 99% of all such tumors occur in the central nervous system; about 95% of these tumors arise in the brain and 5% are in the spine. This has been a difficult site to study across time and geographic areas because of the wide variation in the tumors that are included. The CSP is one of the few U.S. registries that has consistently included benign as well as malignant tumors at this site. These brain tumors are unique because of their location within the bony structure of the cranium. Thus, the types of tumors that account for the bulk of CSP nervous system cases are tumors of the brain, cranial nerves and cranial meninges. Symptoms depend mainly on location, and benign tumors can result in symptoms and outcomes similar to malignant tumors. The most common type of brain tumor is glioma, which is malignant and is more common in men than women. The second most common type, meningioma, is usually benign and is more common in women. Tumors of the cranial nerves arise in the nerve sheath, and 9% of these occur on the eighth or acoustic nerve and are known as acoustic neuromas; these account for about 8% of primary intracranial tumors in both men and women. All three major types of brain tumors are related to high-dose ionizing radiation, such as occurs in radiation treatment for medical conditions. This association is strongest for neuromas, intermediate for meningiomas and weakest for gliomas. It is not known whether lower doses of radiation such as those associated with diagnostic radiography increase the risk, but some studies have suggested associations with cumulative exposure from medical and dental X-rays including exposures several decades ago when doses used for diagnosis were up to one hundred times higher than now. Our current knowledge of other risk factors for brain tumors is limited. Much controversy surrounded the question of whether the incidence of brain tumors was increasing in the decades before 199, but most of this increase is thought to relate to improved brain imaging techniques, allowing for more complete diagnosis. This trend is seen particularly among those over the age of 65 years who showed the greatest increase in rates. TRENDS IN INCIDENCE IN LOS ANGELES COUNTY Clear examination of trends in brain tumor incidence, in particular by ethnic group and tumor subtype, is limited by the low incidence of the disease. Among non-latino white men, incidence rates of all tumors of the brain and other nervous system increased from 1976 to 1995 and then declined. This pattern is also seen among Latino white men and black men, although the data are more unstable because of smaller numbers. Women, for whom the benign tumors comprise a larger proportion of all brain and other nervous system tumors, show a gradual increase in incidence rates from 1976 to 2 among the non-latino white, Latina white and black populations.