Research has consistently shown that Native American and Alaska Native individuals are among the most underserved minority populations in the United States and are disproportionately affected by cancer. The results from a 50-year report by the Alaska Native Tribal Health Consortium’s Alaska Native Tumor Registry found that about 4 in 10 Alaska Native men and 5 in 10 Alaska Native women will be diagnosed with cancer in their lifetime.1
This population also has the lowest survival rates for nearly all types of cancer of any minority group. A recent study by the American Cancer Society found that overall cancer mortality among Native American and Alaska Native individuals is 18% higher than it is among White individuals, even though they have a similar cancer incidence. However, the study showed that disparities vary widely depending on cancer type and geographic region. For example, breast cancer and prostate cancer incidence rates are 15% and 12% lower, respectively, although mortality rates are 8% and 31% higher, respectively, in Alaska Native individuals than in White individuals, despite a lower incidence and availability of early detection tests for these cancers.2 They also have much higher rates of certain types of cancer, including lung, colorectal, liver, stomach, and kidney cancers, compared with non-Hispanic White individuals.
Although cancer mortality is high among this patient population, it is not the only leading cause of death. Heart disease, unintentional injuries, diabetes, chronic liver disease and cirrhosis, assault/homicide, intentional self-harm and suicide, as well as chronic lower respiratory diseases all contribute to the lowest life expectancy in Native American and Alaska Native people compared with all other races in the United States: 73 vs 78.5 years, respectively.3 Life expectancy is even lower among specific Native American populations for whom poverty is extreme.
Anusiyanthan I. Mariampillai, MD
To help combat these grim statistics, the Alaska Native Tribal Health Consortium, a nonprofit tribal health organization in Anchorage, in partnership with the Alaska Tribal Health System, is serving more than 2,000 Alaska Native patients with cancer each year across the state. During the Union for International Cancer Control (UICC) 2023 World Cancer Leaders’ Summit, Anusiyanthan I. Mariampillai, MD, a medical oncologist at the Alaska Native Tribal Health Consortium, spoke about the unique challenges Alaska Native individuals face after a cancer diagnosis.
In a wide-ranging interview with The ASCO Post, Dr. Mariampillai discussed the disparity in cancer incidence and mortality rates in this patient population; the difficulty in providing care for patients across hundreds of thousands of miles with limited oncology practitioners; and the importance of considering patients’ cultural beliefs, supportive care needs, and quality of life when developing treatment plans.
Understanding the Underlying Causes of Cancer Inequities
Please talk about why there is such a disparity in cancer incidence and mortality rates among Alaska Native individuals compared with White individuals. What can be done to reduce cancer incidence and mortality among this patient population?
There are a number of factors that account for the unique cancer patterns and health disparities found in Native American and Alaska Native populations compared with White populations, including history and culture; inherent genetic differences that predispose Alaska Natives to develop cancer; their geographic location; accessibility to care (including the availability of cancer screenings); lifestyle choices (such as smoking and alcohol use); and institutionalized racism. So, it’s a combination of biology and social and external factors that play a role in cancer disparities in this population.
Obstacles to Improving Care
What are some of the greatest obstacles to improving care and reducing cancer disparities for Alaska Native individuals in your center and throughout Alaska?
We at the Alaska Native Tribal Health Consortium serve patients across the entire state, which covers more than 665,000 square miles of rugged terrain covered by tundra, glaciers, and forests. This area also includes Kodiak Island and the Aleutian Islands. Our small clinic, which has only 5 oncologists, is the sole location for cancer care for the nearly 242,000 Alaska Natives in the state. Each year, we provide care for more than 2,000 patients.
We have a wonderful facility. It is one of the largest Indian Health Service facilities in the country, but the combination of high cancer rates and limited medical personnel is an issue across the whole country. This problem is not unique to Alaska.
That said, attracting oncologists to come here and provide cancer care for Indigenous populations is a challenge. However, there are other challenges as well, including getting patients to Anchorage for treatment from across the state.
We can have the most effective and expensive cancer treatments that increase overall survival, but it should be everyone’s goal to prevent cancer from ever developing.— Anusiyanthan I. Mariampillai, MD
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Cancer Prevention Strategies
How can cancer incidence and mortality rates among Alaska Native individuals be reduced?
To reduce cancer incidence and mortality in this population, adherence to all prevention strategies is key, including improving the rate of cancer screening tests and making sure preventive health-care services and programs are available to help people quit smoking, reduce alcohol consumption, maintain a healthy weight, and increase physical activity. Generally, cancer prevention begins at the primary care level to educate patients about the importance of living a healthy lifestyle to reduce their risk of developing cancers in combination with community programs. Such programs can promote cancer prevention education through mobile clinics that provide screening tests and other routine clinical care to detect cancers at an early, more curable stage.
Ultimately, we want to reduce a person’s risk for cancer. One of the most effective ways to reduce cancer incidence and mortality is to prevent cancer from developing. We can have the most effective and expensive cancer treatments that increase overall survival, but it should be everyone’s goal to prevent cancer from ever developing.
Cancer Treatment and Concerns About Patients’ Livelihood
During your presentation at the UICC World Cancer Leaders’ Summit, you talked about the concerns your patients have about how their treatment side effects might impact their quality of life and ability to work. Please talk about some of their concerns and how you address their fears.
All of our cancer planning and treatment decision-making is based on an intimate conversation with our patient. We discuss goals of care, quality of life, and how cancer and its treatment might affect the patient’s life. One of the unique challenges—and benefits—of living in Alaska is its natural beauty and remoteness.
Many of our patients fish and hunt for their primary source of food and income, so it’s important to take that information into consideration when determining the most effective treatment and how that treatment might impede patients’ ability to work and continue to provide food for their families. It’s not like living in an urban center, where you can go to Whole Foods and pick up groceries for the week.
A lot of our patients plan the seasons around the best months for moose and whale hunting and for planting their vegetable gardens. If you are a patient on cancer treatment, and you know that hunting, whaling, and planting seasons take place at certain times of the year, that becomes a question of when to realistically receive care.
We take this information into consideration when devising an effective treatment plan. We don’t compromise cancer care to accommodate these concerns, but taking their concerns into consideration is very important to our patients. We also give careful thought to how treatment side effects might impact patients’ ability to work. If a patient is on a fishing expedition, having diarrhea from treatment in the middle of the ocean is not a good idea.
We give careful thought to how treatment side effects might impact patients’ ability to work.— Anusiyanthan I. Mariampillai, MD
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We prepare patients in advance for any potential treatment side effects and try to choose treatments that have few side effects but are still efficacious. When possible, we use oral therapies to keep patients out of the infusion center and immunotherapies with more extended dosing schedules, for example, administering pembrolizumab every 6 weeks instead of every 3 weeks. Also, when we can, we use single treatment options such as chimeric antigen receptor T-cell therapy, which has been a game changer for many of our patients. In addition, we offer video conferencing to evaluate treatment toxicities and other treatment-related concerns, so patients can stay close to their villages and don’t have to travel far from their homes for routine follow-up visits.
Progress is being made in cancer awareness and in the importance of cancer screenings for early detection. People in our Indigenous community, especially younger people, are becoming better educated about cancer and are aware that cancer is a treatable, curable disease when detected early.
Our goal is to encourage everyone to get cancer screenings and to seek medical attention early to cure more cancers, and we are seeing improvement in these areas. Hopefully, we will start to reap the benefits of these efforts and see cancer incidence and mortality rates decrease in Indigenous populations.
DISCLOSURE: Dr. Mariampillai reported no conflicts of interest.
REFERENCES
1. Alaska Native Tribal Health Consortium: Cancer Among Alaska Native People: An Executive Summary of the Alaska Native Tumor Registry’s 50-Year Report. Available at http://anthctoday.org/epicenter/antr/Alaska_Native_Cancer_Report_50_Year_Executive_Summary.pdf. Accessed July 8, 2024.
2. Kratzer TB, Jemal A, Miller KD, et al: Cancer statistics for American Indian and Alaska Native individuals, 2022: Including increasing disparities in early onset colorectal cancer. CA Cancer J Clin 73:120-146, 2023.
3. U.S. Department of Health and Human Services, Indian Health Service: Disparities. Available at www.ihs.gov/newsroom/factsheets/disparities/. Accessed July 8, 2024.
