reported 33 percent increase in the American Indian population between 1960 and 1990 that reflects increased preference to self-report as an American Indian.

    2.  

    Age-specific death rates, especially those for the elderly, are under-reported.

    3.  

    Hispanic origin and "race" are separate items. NCHS picked the best rates going across these two variables, but show the deaths for both Hispanic origin and "race."

    4.  

    Hispanic origin was not reported on all state death certificates in this time period. The rates used in the calculation were based on 46 states and the District of Columbia. The observed death count was inflated to a national total by using the reciprocal of the fraction of the Hispanic population living in these 46 states and D.C.

    5.  

    The number of events, particularly at young ages for certain ethnic minority groups, are small. This would affect the stability of the rates. To counter that tendency, NCHS used data for the 1991–95 time period. In the summary table, NCHS has expressed the number of deaths in terms of a single year of data.

    6.  

    The reduction for all cancer sites combined differs depending on whether the values are summed across specific sites or is done separately. The reduction is greater when the values are summed.

These cautions are valid regardless of the approach that is used and serve to indicate the limitations of the data that one continuously faces. Any or all of the methods could be used whether the primary focus is on the general population, on ethnic minority groups, or on the medically underserved population.

It may be useful to present the information in several forms. Another method would be to measure progress against the objectives defined for the nation, such as the objectives outlined in Healthy People 2000 (U.S. Public Health Services, 1991) or Healthy People 2010. The national objectives are set on the basis of what is known to be preventable. Objectives were set for total cancers and for cancers of the lung, breast, cervix, and colon-rectum. The objectives were based on the assumptions of improved tobacco control, increased rates of use of mammography and the Pap smear, and both the early detection of and improvements in treatments for colorectal cancer. Goals were not set for prostate cancer, awaiting evidence of methods of effective prevention or treatment. In some cases Healthy People has set specific targets for some ethnic minority groups.

The summary data can be refined and presented in separate tables on the distribution of cancer by age and sex for each ethnic group, averages over a specific period, annual rates, and trends over a prolonged period. The trends in mortality are very important because this is a matter of



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