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CA Cancer J Clin 2002; 52:326
doi: 10.3322/canjclin.52.6.326
© 2002 American Cancer Society
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Cancer Statistics for African Americans

Asma Ghafoor, MPH, Ahmedin Jemal, PhD, DVM, Vilma Cokkinides, PhD, MSPH, Cheryll Cardinez, MSPH, Taylor Murray, Alicia Samuels, MPH and Michael J. Thun, MD, MS

Ms. Ghafoor is Epidemiologist, Department of Epidemiology and Surveillance Research, American Cancer Society, Atlanta, GA.
Dr. Jemal is Program Director for Cancer Occurrence, Department of Epidemiology and Surveillance Research, American Cancer Society, Atlanta, GA.
Dr. Cokkinides is Program Director, Risk Factor Surveillance, Department of Epidemiology and Surveillance Research, American Cancer Society, Atlanta, GA.
Ms. Cardinez is Epidemiologist, Department of Epidemiology and Surveillance Research, American Cancer Society, Atlanta, GA.
Mr. Murray is Research Analyst, Surveillance Data Systems, Department of Epidemiology and Surveillance Research, American Cancer Society, Atlanta, GA.
Ms. Samuels is Manager, Surveillance Information Services, Department of Epidemiology and Surveillance Research, American Cancer Society, Atlanta, GA.
Dr. Thun is Vice President for Epidemiology and Surveillance Research, American Cancer Society, Atlanta, GA.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 SELECTED FINDINGS
 LIFESTYLE AND SOCIAL RISK...
 DATA LIMITATIONS AND FUTURE...
 REFERENCES
 
The American Cancer Society provides estimates on the number of new cancer cases and deaths, and compiles health statistics on African Americans in a biennial publication, Cancer Facts and Figures for African Americans. The compiled statistics include cancer incidence, mortality, survival, and lifestyle behaviors using the most recent data on incidence and survival from the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results (SEER) program, mortality data from the National Center for Health Statistics (NCHS), and behavioral information from the Behavior Risk Factor Surveillance System (BRFSS), Youth Risk Behavior Surveillance System (YRBSS), and National Health Interview Survey (NHIS). It is estimated that 132,700 new cases of cancer and 63,100 deaths will occur among African Americans in the year 2003. Although African Americans have experienced higher incidence and mortality rates of cancer than whites for many years, incidence rates have declined by 2.7 percent per year in African-American males since 1992, while stabilizing in African-American females. During the same period, death rates declined by 2.1 percent and 0.4 percent per year among African-American males and females, respectively. The decrease in both incidence and death rates from cancer among African-American males was the largest of any racial or ethnic group. Nonetheless, African Americans still carry the highest cancer burden among US racial and ethnic groups. Most cancers detectable by screening are diagnosed at a later stage and survival rates are lower within each stage of disease in African Americans than in whites. The extent to which these disparities reflect unequal access to health care versus other factors is an active area of research.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 SELECTED FINDINGS
 LIFESTYLE AND SOCIAL RISK...
 DATA LIMITATIONS AND FUTURE...
 REFERENCES
 
In 2003, approximately 1.3 million Americans will be diagnosed with invasive cancer.1 Racial/ethnic minorities are expected to account for a disproportionate number of these cancers. African Americans, in particular, have a 10 percent higher incidence rate and a 30 percent higher death rate from all cancers combined than whites.2 In this paper, we provide updated data on cancer incidence, mortality, survival rates, and several lifestyle behaviors relevant to cancer in African Americans.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
SELECTED FINDINGS
 LIFESTYLE AND SOCIAL RISK...
 DATA LIMITATIONS AND FUTURE...
 REFERENCES
 
    Data Sources
Incidence and five-year relative survival data were obtained from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute, which covers about 10 percent of the US population.2 Population data were obtained from the US Census Bureau.3 Mortality data were obtained from the National Center for Health Statistics.4 For 1999 mortality data, causes of death were coded and classified according to the Tenth Revision of the International Classification of Diseases (ICD-10)5 replacing ICD-9 coding used in the United States for deaths occurring during 1979 to 1998.6 Cancer cases were classified according to the International Classification of Diseases for Oncology.7 Data on behavioral risk factors were obtained from state and national population-based surveillance systems (the Behavioral Risk Factor Surveillance Systems,8 Youth Risk Behavior Surveillance Survey,9 and National Health Interview Survey).10

    Estimated New Cancer Cases
New cancer cases are estimated because the United States has no nationwide cancer registry. Therefore, exactly how many new cases of cancer are diagnosed each year in the United States and in each individual state is unknown. Consequently, we first estimated the number of new cancer cases occurring annually in the United States from 1979 through 1999 using the age-specific cancer incidence data collected by NCI’s SEER program coupled with population data reported by the US Census Bureau. Using an autoregressive quadratic model11 based on cases from those previous years, we forecast the number of cases expected to be diagnosed in the United States in the year 2003.

The autoregressive model used to estimate incident cases for other cancers was not compatible with the trends observed in prostate cancer incidence rates, however, because rates increased quickly between 1988 and 1992 and then declined just as sharply from 1992 to 1995, and then eventually leveled off from 1995 to 1999. This trend likely reflects the widespread use of prostate-specific antigen (PSA) screening and the subsequent increase in early-stage cancer diagnoses in a previously unscreened population. Because the temporal trends in prostate cancer incidence now approximate that observed prior to the widespread use of PSA screening, we estimated the number of incident cases using a linear model based on data from 1979 to 1989 and 1995 to 1999 only.

The above-mentioned method cannot be used to estimate the number of cases for individual states, since many have incomplete registration of new cases. To derive the estimates, we relied on mortality data from each state, and assumed that the ratio of cancer deaths to cancer cases was the same for individual states as for the United States as a whole.

    Estimated Cancer Deaths
To estimate the number of cancer deaths expected to occur in the United States and in each state in the year 2003, we used the underlying cause-of-death data from death certificates as reported to the National Center for Health Statistics. Using the aforementioned regression model11 on recorded number of cancer deaths occurring annually from 1979 to 1999, we forecast the number of cancer deaths expected to occur in 2003.

    Other Statistics
Trends in cancer incidence, mortality, and five-year relative survival rates for selected cancers are provided based on data from 1973 through 1999.2 Cancer incidence and death rates are standardized to the 2000 US standard population and expressed per 100,000 person-years. We also provide mortality statistics for the leading causes of death (Table 1Go) and rate ratios for African Americans relative to whites (Tables 2 and 3GoGo). This report also provides recent prevalence estimates of behavioral factors related to cancer (i.e., tobacco use, physical activity, use of cancer screening); these estimates are derived from national and state population-based surveys of adults and youths. The Youth Risk Behavior Surveillance System, a survey of high school students, is routinely administered in all randomly-selected schools in participating states (or large metropolitan cities); consenting students self-report their behavioral infor-mation. The Behavioral Risk Factor Sur-veillance System and the National Health Interview Survey are administered annually to adults by telephone and in-person, respectively. The methodological sampling techniques used in these surveys assure the random selection of participants. Therefore, appropriately-weighted estimates are considered representative of the adult (aged 18 and older) civilian population. The weighted estimates are calculated in SUDAAN, a specialized program that adjusts for varying sampling selection, non-response, non-coverage, and other post-stratification factors in calculating point estimates and standard errors.


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  		TABLE 1 Leading Causes of Death by Rank Among African Americans and Whites, 1999
 

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  		TABLE 2 African American to White Incidence Rate Ratios, US, 1995 to 1999*
 

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  		TABLE 3 African American to White Mortality Rate Ratios, US, 1995 to 1999*
 

   SELECTED FINDINGS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 SELECTED FINDINGS
LIFESTYLE AND SOCIAL RISK...
 DATA LIMITATIONS AND FUTURE...
 REFERENCES
 
    Expected Numbers of New Cancer Cases
In the year 2003, about 132,700 new cancer cases are expected to be diagnosed among African Americans (Figure 1Go). The most commonly diagnosed cancers among African-American men will be prostate cancer (39 percent), followed by cancer of the lung (16 percent), and colon and rectum (9 percent). The most common cancers among African-American women will be breast (31 percent), followed by lung (13 percent), and colon and rectum cancers (13 percent).


Figure 1
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  		FIGURE 1
 
    Expected Numbers of Cancer Deaths
About 63,100 African Americans are expected to die from cancer in 2003 (Figure 1Go). Lung cancer accounts for the largest number of cancer deaths among both men (29 percent) and women (21 percent), followed by prostate cancer in men (16 percent), and breast cancer in women (19 percent). For both men and women, cancer of the colon and rectum and cancer of the pancreas are expected to rank third and fourth, respectively, as the leading causes of cancer death.

    Comparative Cancer Rates in African Americans and Whites
Tables 2 and 3GoGo show rate ratios in descending order for selected cancers in which incidence and death rates are greater or smaller in African Americans compared with whites. In African-American males, the incidence rate ratios range from 2.0 for myeloma to 0.5 for urinary bladder. In general, the pattern seen in males is similar to that observed in females; however, incidence rate ratios are greater for African-American females. Similar disparities exist for death rates between African Americans and whites. In males, death rate ratios range from 2.4 for laryngeal cancers to 0.1 for melanoma. Among females, death rate ratios range from 2.3 for stomach cancers to 0.2 for melanoma.

    Trends in Cancer Incidence and Mortality
In African Americans, incidence rates for all cancers combined increased from the early 1970s to early 1990s in both males and females, although the incidence rates were higher and increased faster in males than in females (Figure 2Go). During the 1990s, however, rates decreased in African-American males while stabilizing in African-American females. The decrease in incidence rates in men largely involved cancers of the lung and prostate. The mortality rate for all cancers combined increased among African Americans from 1973 to 1992, but decreased after 1992, by 1.2 percent per year on average (Figure 2Go). The decline for African-American males (2.1 percent per year since 1993) was larger than the decline for African-American females (0.4 percent per year since 1991).


Figure 2
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  		FIGURE 2
 
    Female Breast
Breast cancer is the most common cancer among African-American women; however, the incidence rate of newly-diagnosed cases is about 13 percent lower than in white women. Breast cancer incidence has increased since the late 1970s, although there has been little change during the 1990s (Figure 3AGo). The increase may be attributable to earlier and greater diagnosis through increased use of breast cancer screening methods, particularly mammography. Breast cancer death rates also increased from 1973 to 1993 (Figure 4AGo) but declined thereafter, especially in younger women. The breast cancer death rate is 28 percent higher in African-American women than in white women, even though incidence for all ages combined is lower in African-American women. This racial differential may be due, in part, to latter stage at diagnosis,12 to differences in access to treatment,13 or to a greater likelihood of being diagnosed with estrogen-receptor-negative or more aggressive tumors that are less responsive to therapy.14,15


Figure 3A
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  		FIGURE 3A
 

Figure 4A
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  		FIGURE 4A
 
    Prostate
Prostate cancer accounts for about 39 percent of all cancer cases diagnosed in African-American males (Figure 1Go). In 1999, the prostate cancer incidence rate was 58 percent higher in African-American men than in white men. From 1989 to 1992, prostate cancer incidence rates increased by 20.6 percent per year, but between 1992 and 1996, the incidence rate declined by approximately 5.7 percent per year. Incidence rates stabilized in the time period between 1996 and 1999 (Figure 3BGo). The dramatic short-term increase in prostate cancer incidence rates between 1989 and 1992 was likely due to earlier and more complete diagnosis through increased use of prostate-specific antigen (PSA) blood screening. Prostate cancer ranks as the second most common cause of cancer deaths among African-American males. Among ethnic and racial groups, African-American males have the highest mortality rate. The death rate from prostate cancer in African-American men has been decreasing by 2.5 percent per year since 1993, after a long-term increasing trend (Figure 4BGo). Some of the decrease in mortality appears likely to be due to screening; however, the relative contribution of screening versus treatment is unknown.16 The decline in prostate cancer mortality began later in African-American men than in white men and has occurred more gradually.


Figure 3B
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  		FIGURE 3B
 

Figure 4B
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  		FIGURE 4B
 
    Lung and Bronchus
More African Americans die from lung cancer than from any other cancer, and lung cancer mortality rate is higher among African Americans than in any other racial or ethnic group. However, lung cancer incidence rates have decreased by 1.6 percent per year since 1984 among African-American males, while rates have remained stable since 1990 in African-American females (Figures 3A and 3BGoGo). Death rates among African-American males have also decreased substantially beginning in 1993 while continuing to increase in African-American females (Figures 4A and 4BGoGo). The decline in death rates among men is a result of decreases in the prevalence of smoking over the previous 30 years.17

    Colon and Rectum
Colorectal cancer is the third most common cancer among both African-American men and women (Figure 1Go), and the second most common for both sexes combined. The incidence rate of colorectal cancer in African Americans increased rapidly in the 1970s, but has stabilized since the 1980s (Figures 3A and 3BGoGo). By comparison, the colorectal cancer incidence rate in whites increased through the mid-1980s, decreased significantly until 1995, and stabilized thereafter. Factors that may affect colorectal cancer incidence rates include screening, increased polyp removal (which prevents progression to invasive cancers), estrogen and progesterone replacement therapy in women,18 and patterns of diet, obesity, and physical activity or inactivity.19 Colorectal cancer is the third leading cause of cancer death among both African-American males and females (Figure 1Go). Overall, colorectal cancer death rates declined in African Americans from 1985 to 1999; however, the average annual reduction in death rates has been smaller among African Americans than in whites, 0.3 percent versus 1.8 percent, respectively (Figures 4A and 4BGoGo).

    Cancer Survival
Five-year relative survival rates are commonly used to monitor progress in the early detection and treatment of cancer. In general, African Americans with cancer have a lower five-year relative survival rate than whites for each of the eleven selected cancers sites (Figure 5Go) and at all stages of diagnosis (Figure 6Go).20 These differences are believed to reflect a combination of factors such as poverty and less access to medical care. The latter may result in delayed diagnosis of disease (so the cancer spreads to regional or distant sites) (Figure 7Go) and/or suboptimal treatment. Several studies have shown that survival rates are comparable between African Americans and whites when patients receive equal treatment.13,21


Figure 5
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  		FIGURE 5
 

Figure 6
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  		FIGURE 6
 

Figure 7
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  		FIGURE 7
 
The five-year relative survival rate for all cancers combined improved from approx-imately 27 percent during 1960 to 1963 to 53 percent during 1992 to 1998. The correspond-ing survival rates in whites increased from 39 percent to 64 percent during the same period.2


   LIFESTYLE AND SOCIAL RISK FACTORS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 SELECTED FINDINGS
 LIFESTYLE AND SOCIAL RISK...
DATA LIMITATIONS AND FUTURE...
 REFERENCES
 
    Socioeconomic Status
Socioeconomic inequalities strongly influence many aspects of health and chronic diseases, including cancer. Poverty affects nutrition, social support networks, risk-promoting lifestyles, and access to health care. African Americans constitute only 12 percent of the total US population, yet comprise one-third of the nation’s poor.22 Racial disparities exist across the entire spectrum of cancer prevention, early detection, diagnosis, treatment, care, and social support.

    Tobacco
Cigarette smoking causes approximately 30 percent of all cancer deaths in the United States.23 In addition to lung cancer, tobacco use causes cancers of the lip, oral cavity, larynx, esophagus, stomach, pancreas, liver, kidney, urinary bladder, uterine cervix, and myeloid leukemia.24

African-American men aged 18 and above, have a higher prevalence of current cigarette smoking than white men, whereas the opposite is true in women (Figure 8AGo). In general, African Americans begin smoking regularly at an older age and smoke fewer cigarettes per day than do whites. However, African Americans have higher blood levels of cotinine, the major metabolite of nicotine, even when smoking the same number of cigarettes than whites, perhaps because each cigarette is smoked more intensively. The use of cigarettes with higher machine-measured yields of tar and nicotine is more common in African Americans than in whites. These brands are heavily marketed to African-American communities by the tobacco industry.


Figure 8A
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  		FIGURE 8A
 
Current cigarette smoking by African-American high school students increased during much of 1990s, especially in African-American females. In African-American males, the prevalence of current smoking peaked by 1999 and declined significantly by 2001 (Figure 8BGo). These trends parallel the changes in adolescent smoking in other racial and ethnic groups. The recent decrease in youth smoking has been greatest in states that have substantially expanded tobacco control measures by increasing tobacco price (through higher taxes) and using counter-advertising directed at adolescents.


Figure 8B
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  		FIGURE 8B
 
    Physical Activity
Regular physical activity is critical for maintaining a healthy body weight and is associated with lower risk of cancers of the colon and breast. Despite this compelling evidence, in 1999 only one-third of all adults participated in moderate and/or vigorous physical activity, five or more times per week (Table 4Go). In particular, one-third (33.2 percent) of African-American adults reported no leisure-time physical activity, with African-American females more likely to be physically inactive (38.8 percent) than African-American males (29.1 percent). The percentage of adults reporting either moderate or vigorous physical activity was also lower in African Americans than in whites (Table 4).


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  		TABLE 4 Participation in Physical Activity Among Adults by Race and Gender, US,* 2001
 
    Use of Screening Tests
Screening tests are used to detect cancer early, at a stage when the disease is still highly curable. Generally, screening-test utilization is similar between African Americans and whites (Table 5Go). Since 1987, mammography use among African-American females has greatly increased, from 29 percent to 66.7 percent. In contrast, cervical screening (Pap test) has remained unchanged since the early 1990s, although there has been a slight decrease in the percentage of older African-American females receiving a Pap test. The use of colorectal screening tests among African Americans has increased over the past several years, although the percentage of people being screened still remains low.25 Less than one-quarter of African-American and white adults had a fecal occult blood test within the past year (21.6 percent and 24.1 percent, respectively) and less than one-half had a flexible sigmoidoscopy within the past five years (Table 5Go). Prostate cancer screening prevalence (specifically PSA) is similar between African-American and white males, but the use of the digital rectal exam remains low in African-American males.


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  		TABLE 5 Cancer Screening Examinations, 2000 and 2001
 

   DATA LIMITATIONS AND FUTURE CHALLENGES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 SELECTED FINDINGS
 LIFESTYLE AND SOCIAL RISK...
 DATA LIMITATIONS AND FUTURE...
REFERENCES
 
The estimates of new cancer cases and cancer deaths in this report should be interpreted with caution, since these estimates may vary year to year, especially for rare cancers and in states with smaller populations. For this reason, the estimates should not be used to track year-to-year progress in reducing cancer incidence and mortality changes in cancer occurrence and deaths. The NCHS data on cancer deaths and death rates and the SEER data on cancer incidence rates are more informative in tracking trends.

Our estimates are projected from the most recent data available on incidence and mortality; however, available data are three- to four-years old. Unanticipated changes that may have occurred during the last three to four years are not captured by our modeling efforts. Finally, our estimates on cancer incidence rates are based on locations participating in the SEER program, which may not represent the entire United States.

The behavior data used in this report were derived from the BRFSS, YRBSS, and NHIS. These are state and national sources for behavioral data from population-based surveys. Participants’ self-reported information was used to derive estimates of behavior. No attempts were made to validate the self-reports. Adjustments for sample selection and non-response were made in the calculation of the estimates.

Despite these limitations, our estimates highlight the disproportionate burden of cancer in African Americans, which may, in part, be related to unequal access to medical care and differences in the receipt of treatment. Increased efforts to alleviate economic disparities and increase access to high-quality medical care along with culturally appropriate community-based interventions that affect healthy behavioral changes can help lessen the burden of cancer in African Americans.


   Footnotes
 
This article is available online at http://CAonline.AmCancerSoc.org


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 SELECTED FINDINGS
 LIFESTYLE AND SOCIAL RISK...
 DATA LIMITATIONS AND FUTURE...
 REFERENCES
 

  1. American Cancer Society. Cancer Facts and Figures, 2003. American Cancer Society, Atlanta, GA, 2003.
  2. Ries LAG, Eisner MP, Kosary CL, et al. (eds). SEER Cancer Statistics Review, 1973-1999, National Cancer Institute. Bethesda, MD. Available at: http://seer.cancer.gov/csr/1973_1999/. Accessed September, 2002.
  3. US Census Bureau. Available at: http://www.census.gov. Accessed May, 2002.
  4. National Center for Health Statistics, Division of Vital Statistics, Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/nchs/nvss.htm. Accessed May, 2002.
  5. Manual of the international statistics classification of diseases, injuries, and causes of death: Volume 1, tenth revision. World Health Organization, Geneva, 1992.
  6. Manual of the international statistics classification of diseases, injuries, and causes of death: Volume 1, ninth revision. World Health Organization, Geneva, 1975.
  7. Percy C, Van Holten V, Muir C (eds). International classification of diseases for oncology, ed 2. World Health Organization, Geneva, 1990.
  8. Behavioral Risk Factor Surveillance Systems, 1990, 1992, 1994, 1995, 1997, 1998, 1999, 2000. Centers for Disease Control and Prevention, Atlanta, GA.
  9. Youth Risk Behavior Surveillance Survey, 1991, 1993, 1995, 1997, 1999, 2001. Centers for Disease Control and Prevention, Atlanta, GA.
  10. National Health Interview Survey, 1990, 1992, 1994, 1995, 1997, 1998, 1999, 2000. National Center for Health Statistics, Centers for Disease Control and Prevention, Atlanta, GA.
  11. Wingo PA, Landis S, Parker S, et al. Using cancer registry and vital statistics data to estimate the number of new cases and deaths in the United States for the upcoming year. J Reg Management 1998;25:43–51.
  12. Bradley CJ, Given CW, Roberts C, et al. Race, socioeconomic status, and breast cancer treatment and survival. J Natl Cancer Inst. 2002;94:490–496.[Abstract/Free Full Text]
  13. Shavers VL, Brown ML, et al. Racial and ethnic disparities in the receipt of cancer treatment. J Natl Cancer Inst. 2002;94:334–357.[Abstract/Free Full Text]
  14. Ries LAG, Wingo PA, Miller DS, et al. The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer. Cancer 2000;88:2398–2424.[CrossRef][Medline]
  15. Chen VW, Correa P, Kurman RJ, et al. Histological characteristics of breast carcinoma in blacks and whites. Cancer Epidemiol Biomarkers Prev 1994;3:127–135.[Abstract]
  16. Potosky AL, Feuer EJ, Levin DL. Impact of screening on incidence and mortality of prostate cancer in the United States. Epidemiol Rev 2001;23:181–186.[Free Full Text]
  17. Thun MJ, Henley SJ, Calle EE. Tobacco use and cancer: An epidemiological perspective for geneticists. Oncogene 2002;00:1–19.[CrossRef]
  18. Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. JAMA 2002;288:321–333.[Abstract/Free Full Text]
  19. IARC working group on the evaluation of preventive agents. (2002). IARC handbook on cancer prevention. Vol. 6: Physical activity and weight control. Lyon, France: IARC Scientific Publication.
  20. Bradley CJ, Givens CW, Roberts C. Disparities in cancer diagnosis and survival. Cancer 2001;91:178–188.[CrossRef][Medline]
  21. Bach PB, Schrag D, Brawley OW, et al. Survival of blacks and whites after a cancer diagnosis. JAMA 2002;287:2106–2113.[Abstract/Free Full Text]
  22. Freeman HP. Cancer in the socioeconomic-ally disadvantaged. CA Cancer J Clin 1989;39: 266–288.[Abstract/Free Full Text]
  23. International Agency for Research on Cancer. IARC Monographs, Vol. 83: Tobacco Smoke and Involuntary Smoking. World Health Organization, 2002.
  24. US Department of Health and Human Services. Tobacco Use Among US Racial/Ethnic Minority Groups—African Americans, Native Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1998.
  25. Anderson LM, May DS. Has the use of cervical, breast, and colorectal cancer screening increased in the United States? Am J Public Health 1995;85:840–842.[Abstract/Free Full Text]



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