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LLS. DEP~ OF HEALTH AND I"IUMA, N SERVICt~ Pub|lc Hea|th Service National Institutes of Health Populations at L~ Ris}~ of Cancer NCI Mo, nograph T109371645

Journal of the National Cancer Institute l~In~ 1980 Volume 65 Number 5 Table of Contents Vol. 65, No. 5~November 1980 Monograph: Populations at Low Risk of Cancer Cancer and Mortality in Religious Groups 1055 Cancer incidence in Mormons and non- Mormons in Utah during 1967-1975 1063 Cancer in Utah: Risk by religlon and place of residence 1075 Cancer mortality among Mormons in California during 1968-75 1083 Cancer risk factors: An analysis of Utah Mormons and non-Mormom I097 Mortality among California Seventh-Day Adventists for selected cancer sites 1109 Cancer mortality in a human isolate !115 American white Protestant clergy as a low- risk population for mortality research Cancer Patterns in Ethnic Croups 11.2"/ Cmcrr lxlltems or rour ethnic grotlps in Ilawaii IIII C~ncrr mo,tallty among Chinese i.n the I.'nltc~ Stat,:s Cmcrr moltality risk among .Japanese in the Unltcd States 1157 C.ttlo.-r in Alaskan Iudians, Eskimos, and J. L. L),on, ]. W. Gardner, D. W. West ]. L. Lyon, ]. W. Gardner, D. W. West James E. Enstrom D. W. West, ]. L. Lyon, ]. W. Gardner Roland L. Phillips, Lawrence Garfinkel, ]. W. Kuzma, W. Lawrence Beeson, Tero Lotz, Burton Brin Alice O. Martin, Judith K. Dunn, ]pc L. Simpson, Carolyn L. Olsen, Sam Kernel, Michael Grace, Sherman Elias~ Gloria E. Saree, Bion Smaller, Arthur G. Steinberg Haitung King, Frances B. Locke La.u, rence N. Kolonel Haitung King, Frances B. Locke Frances B. Locke, Haitung King dnne P. Lanier, William ]. Blot, Thomas R. Bender, ]oseph F. Fraumeni, It, Cancer Mortality in Nonsmokers in the United States 1163 Cancer mortality among nonsmokers in an E. Rogot, .I. Murray insured group o~ U.S. veterans 1169 Cancer mortality in nonsmokers: Prospective Lawrence Carfinkel study by the American Cancer Society 1175 Cancer mortality among a representative James E. Enstronf, Frank H. Godley sample of nousmokers in the United States during 1966-68 Summary and Comments on the Workshop 1187 High-rate cancers among ]owqisk popola- tip,s ll~l Appendix i I~B Pa~t icipams Ioseph F. Fraum.eni. Jr. T109371646

Populations at Low Risk of Cancer Sponsored B~: Field Studies and Statistics Pro~a'am Division of Cancer Cause and Prevention National Cancer Institute National Institutes of Health Beth~la. Maryland A Workshop held in Snowbird, Utah August 25--o5, 1978 Editorial Committee Chairman: Brian MacMahon Gcnro~e Cooley Joseph F. Fraumeni, Jr. Pete~ Grcenwald William T109371647

Cancer and Mortality in Religious Groups Moderators: Mark Skolnick, Ph.D. Mary C. King, Ph.D. TIO~7 lr:~t8

i Cancer Incidence in Mormons and Non-Mormons in Utah During 1967-75 J. L Lyon, M.D., M.P.H., ~" 4 j. W. Gardner, M.D.,. M.P,H., ~ and D. W. West, Ph.D, ABSTRACT~Oatl from the Utah Cancer Registry w~m uxd to compare cancer incidence In Mormons and non-Mormons In Utah k)r the I~dOd 1967-75, Chul~h membership was Identified for gT.~ of the 20,379 ¢al~s In Utah by a torch of the c~ntral m~nb~r~hlp fllel of the ChurCh of Jesus Christ of LatteP-Day Saintl (or Mormon Church). Sites associated with smoking (lung, lewnx, pharynx, orel cav'd~, e~ophagu~, and urinary bledder) Ihowld an Incidence in Mormons at about one-half thet of non- Mormons. RIt~'a of centers of the breast, cervix, and ovary wore low in Mormon wench: the rate for cervical cancer wls about one-half of that obl~rvld in non-Mormons. Cancers of the ltomach, colon-rectum, and pencreas were about one-third lower in Morrnona than in others who ere not members of thia religious group, Mo~t of the differences sHn in clncor incidence can be explained by Mormon teachings regarding sexual activity and • lc0hol and tobacco ux, but some differences (e.g., colon and stomach) remain unexpl~in~cL---JNCI ~ 10~5-10$I, 1980, That personal habits have a significant influence on the development of various malignant neoplasms has been established, and the association of these factors with tumor development continues to be a main focus of epidemiologic research. Large groups whose mem- ber~ have similar known life-styles offer opportunities for epidemiologic study of certain risk lactors and their consequent association with malignant diseases. We have used the data accumulated by the Utah Cancer Registry to describe cancer incidence in Utah (1) and in the large (900,000 or over 70%) Mormon population of the State (2). Thus the Utah Cancer llegistry is the . largest single source of cancer incidence data on the Mormon population available in the world. The Church of Jesus Christ of Latter-Day Saints (Mormon) was founded in 1850. From the beg/nning, it has been an evangelical Church, and its membership has increased to include over 4 million meml~rs worldwide. Beginning in 1847, the Mormons settled in the Great Basin area, includir~ Utah, for the next 50 years. Tens of thousands of converts immigrated to tlds area from all parts of the world, with most of them coming from Canada, Northern Europe, and other parts of the United States. Thus the history of the Great Basin and of the State of Utah has been shaped by the Mormon Church and has produced a large, homogeneous population with a fairly uniform li~e- style (3). Some beliefs and practices of the Mormon Church that may relate to its members' state of health include emphasis on family flee, education, strict sexual mores, and abstinence Erom alcohol, toixacco, tea, coffee, and nonmedicinal drug~. Emphasis on the family places high value on children and homemaking, which likely explains why the State has had the highest birth rate in the nation for many decades H). The emphasis on education has put the Sta~e ahead of other Sta~es in educational achievement; therefore, Morrnous are dis- proportionately overrepresented in the science and business worlds (~). Because the strict sexual mores proscribe all premarital and extramarital sexual inter- course for both men and women, Utah has been among the lowest of all States in the incidence of venereal diseases and percentage of il]eg/dmate births for many years (6). The use of alcohol, tobacco, coffee, tea, and nonmedicinal drugs is prohibited by the "Word of Wisdom," a law of health given by Joseph Smith in 18S$ and to which active Mormons adhere (3, 2). Our pre~ous studies demonstrated that cancer inci- dence in Utah is £0--S0% below that expected from national rates and this is primarily due to the lower incidence in its Mormon population. Cancer incidence for all smoking-related sites and for the female sites of breast, cervix, and ovary in Mormons was significantly lower compared wid~ that in non-Mormon and na- tional populations. Colorectal cancer was also seen to have a lower incidence in Utah. We have instituted several studies o~ specific cancer sites in Utah; these include reviews of cancer of the cervix (~), malignant melanoma (8), and prostate cancer (9) and case-control studies of cervical, colon, ovarian, bladder, and brain cancers. Most of these investigations are still in prog- ress, and other detailed ones are planned. We have also used the Utah Bureau of Vital Statistics to in- vestigate cardiovascular disease (I0) and cerebrovascu- lar disease (Lyon JL, Bishop C, Nielsen N: Unpub- lished observations) in Mormons and non-Mormous. This report details cancer incidence in Mormons and non-Mormons in Utah for 1967 through 1975. ~ Presented at the Workshop on Populadons at ~w ~k ~ ~r ~ at Snowbi~, Utah, August 2]~. l~& ~ Sup~ in ~ by Public H~I~ ~ ~ntmct ~1- ~ from ~e H~d St~i~ and Statistics ~o~m. ~si~ d ~n~ ~u~ a~ ~don, ~tlonal ~n~r lmdtu~. ~ ~visi~ ~ Ep~em/ol~. ~ent of Family ~ ~ ~nhy M~i~. ~ ~e U~h ~r R~s~. Uni~ity of U~h ~l~e~ ~ M~i~ne. ~h ~e City. U~h ~ " Add~ wp6nt ~s~ to Dr. Lyon at the ~r~ent ~ Family and ~mm~hy ~icine. J'NCL VOL. ~5. NO. 5. .'~01¢~Ma£g I~ T109371649

MA~ ANOD The Utah Cancer Regisu--y was established in 1966 to register cancer cases for the entire population of the State. In 1973, the Registry became a member of the NCI SEER Program of cancer registries. SpedaI efforts to ensure completeness of reporting were described in (/, 2). In 1967-75, the 20,$79 case~ of caner d~agnosed in Utah residents were identified by the Registry. Table I gives the percentage of cancers hhtologically verified by site and those identified only by death certificate. Data for IM6, incIuded in our previous reports, were excluded from dds study because of probable overstate- merit of incidence dm-ing the F~ y~r o~ ~m ~ll~- don ~ ~e esmb~t of ~e ~pu~fion-~ ~ ca~ ~s clarified a~ng ~ ~m~rship in • e Me.on ~h. ~rminm~t d mem~rship ~s made ~ssible with ~e u~ of the central mem~r- s~p file, wh~h ~ d~ in devil (10). ~e ma~i~ ~du~ i~lud~ ~rch of all ~n~l ~u~h mem~hip fiI~ of ~e living ~d d~d; mashing ~s b~d on name, county of redone, y~r of bird, and ad~do~l i~o~ation when n~ed. ICD axie No? Site Percent ICD eocle No.~ Site Percent 140 Lip 98 180 Cervix uteri 08 141 Tongue 97 181 Plaeenta 142 Salivary gland 95 182 ~erpu, uteri 145-145 Mouth 97 183 Ovm'y'-tubt-llgament 97 M8"-149 Pharynx 97 184 Female genital system lf~0 F~ophteus 91 18~ Prmtat~ gland 94 151 Stem~eh 88 186 T~t~ 97 lf~, Small intestine 97 187 Male genital s3mt~m 98 1~8 Colen 98 188 Bladder 98 1~4 Rtetura-tnu~ 98 189 Kidney 98 l~ Liver 78 190 Eye lf~ Gallbl~dder 94 191-19~ Brain and central nerveu~ 91 157 Paner,~a 73 ~era 160 Ns~tl eavit~-sinus 98 193 Thyroid gland 98 l~t L~r~x 9"/ 19~ Other end~rine glands ~62 Lun~ 88 Ill.ddln~! sites 16~ Pleura 98 1~ Unknown prim~r~ site 80 164 Media~tinum 95 Lymph, non-Hod~kin's 95 1~ Respiratory ~n-aet 100 Hodt4dn'e disease 98 170 Bone 98 Multiple mysloma 91 171 Connective tissue 97 Aeute leukemia 172 Skin, nmlanoma 98 Chrenie leukemia 98 174 Brea~ (female) 97 Other hematopo[efie sy~mm 83 175 Breast (male) 94 Total site~ 94 The percentage of cases confirmed by death certificate only was 3.2. Coda numbers am from International Classification of DiseMe, (Eighth Revision). Total Utah population Mormon population NowMormon population Mal~ Females Male, Female, Male, Female 0--4 59,916 57,100 43,§72 41,667 16,844 5-9 59,610 57,494 $6,608 $7,$81 28.007 !9,918 10-14 fr2.881 60.489 42.117 44.111 20.764 !6.~78 !5-19 80.084 ~9.$8~ 48,205 48.679. 11.859 " 10.90~ 20~24 49,68~ 5&9~8 40J)98 41,8fl4 9,~89 • 25-29 ~ 40,440 29.865 29.5~8 8.989 ~0-~4 ~0.'/0']' 31.188 21,40~ 22,917 9.894 8,249 85-~9 27,116 27,970 18.8"/6 19,481 8,240 3.f~9 4044 ~.988 27,847 17,~/7 I&790 9.911 8,f~7 45-49 ~6,~91 28.948 17,421 18.~0 8,8~0 8,6"/8 M ~4~ 25~231 14~.779 16,787 9,648 8,444 M9 21.145 21.847 142,43 15685 ¢90£ 6.18~ 60--64 17.549 18. 73"/" 12.0~ 12.881 5J;27 5.8/6 65-69 1~,~16 l&,~6 8~06 11,418 ¢410 3.808 "~0-74 9.720 12.151 5.706 8,173 ¢015 3.9"/8 >-75 12All 18.~.$ 10.0fll 18.,~42 2.380 Total ~0.575 ~&72~ ~80.8~I 400.914 159.754 I,~2.M8 J'NCL VOL ~5. ,~0. 5. .~OVEMBf.~ ]e~e T109371650

C.amm¢ In Mornm~ and Hon-Mormmm 1057 Religiom pt~erence was also verW~-d by search of f~. ~e U~ Moron ~ia~on for July ~nsm ~r~ ~e ~e di~n ~ estimat~ ~m a 5~ ~ys~c ~mple of the ~ur~h ~ken in Aunt 1971 (2, ~0). ~e non-Moron la~on ~ ob~in~ ~ ~ub~on of the Moron ~pula6on from ~he m~l S~te ~ns~, which a~ by liner int~la~on ~ the 1~0 U.S. ~nsm and a 1975 ~pulafion estimate from ~e Utah State Bur~u of Vim] S~tistics. Table 2 gives ~e July 1971 ~pulations by a~. We com~ ~e in~dence of ~n~r in ~e Moron and non-Moron populations of the State wi~h the TN~ mt~ for whit~ usi~ SIR (11). ~e SIR, expre~d in ~rcent, is ~e ~tio of ~ n~r of ~s~ ob~ in ~e ~tive Utah ~pulafion divided by ~e humor exacted in the ~ ~t~ held for that ~pulation. ~e ex~ ~s were ~l~iat~ by appli~on of ~e ~ a~-s~ific inci~nce mt~ m the res~fve Utah ~pulation (with the 5-yr age ~ou~). Smtisti~l s~ifi~n~ of the ~fferences for ~ch ~pula~on from the ~ was ~te~ined ac- cording to ~e me~ of ~lar and Ede~r (12). ~e- adjust~ in~dence ~tes were ~lculac~ by the direct meth~ with ~e 1~0 U.S. white ~pulation used as • e smn~. Diffe~n~s ~tw~n rotes for the 2 ~oups studi~ were ~st~ with a m~ifi~tion of the Mantel- Haenszel pr~dure, which controlled for sex and age in 5-~ age in~s (10, 13). RESULTS Of the 20,379 cases, 439 (2.2%) were excluded because of inability to ascertain religion. Of the 19,940 cases remaining, 12,175 were classified as Mormon and 7,765, as non-Mormon. Text-figure, 1-4 show the SIR for both populations in Utah during 1967-75 for selected sites. Age-adjusted incidence rates are given in table 3. Utah's comparative advantage in cancer incidence. which i~ primarily for Mormom, is clearly reflected. The favorable cancer experience for the State, com- pared with the nation as a whole, has been reported for mortality data that sl~3w Utah has 22~ less cancer mortality than does the United States (14). Previous studies on cancer incidence show Utah had 19.% lower rates than the national, and Mormon and non-Mormon rotes were 25 and 7%, respectively (1, 2). The currem resul, are similar in magnitude for the Church group (26% below TNC,$ rate,), but the non-Mormon rates are now 11% greater than those of the TNCS. Cancer sites having a strong a~ociation with ciga- rette use in other studies (15), e.g., lung, larynx. pharynx, oral cavity, esophagus, and bladder, demon- strated the largest difference between Mormons mad non-Mormons, with the incidence in Mormon men and women 54% below that in the non-Mormons (text- fig. 2). This difference varied from a 69~, difference between Mormons and others for" emOmgeai and laryngeal cancers m a ~ differem~ f~r bladder cancer. Lung cancer, which contributed one-half of the total smoking-associated cases m each group, was 55~ less in the Mormons compared with the non-Mormons. How- ever. the nonoMormons still had rates 18% below those expected from the TNCS. Thu~ the overall rates for non-Mormons in smoking-associated sites were 6% below the TNCS expectation. Rates for breast cancer in Mormon women were 18.% below those expected from the TNCS and ~0% below their counterparts (text-fig. 3). The same pattern was seen for ovarian cancer, but little difference was found in cancer rates for the corpus uteri. Cancer o| the uterine cervix (invasive) followed the same pattern previously reported (2, 6), with rates in Mormon women ~5~ below national rates and 65~ below other whites. The unusual finding of low breast and cervical cancer rates in the same (Mormon) population is still seen° Although the rates for cancers of the prostate gland and testh among Mormons were slighdy higher than expected from the TNCS, they were similar to or lower than the corresponding rates for other whites. Mela- noma was significantly above TNCS expectation in both groups with non-Mormon rates higher than Mormon rates. Lip cancer also presented a similar pattern, though" at a level about three to five times higher than that in the TNCS, which shows that Utah has one of the highest rates for lip cancer in the world (16). Other digestive tract cancer sites showed significant differences between the two groups (text-fig. 4). Can- cers of the stomach, colon, rectum, and pancreas each had rates in the Mormon population that were 80-40% below those expected from the TNCS, whereas rates in non-Mormons differed from those in the TNCS only for female rectal cancer. Cancer of the pancreas has been associated with cigarette smoking, but this is not true for stomach and colon cancers. These two sites usually have an inverse relationship; i.e., if one is high, the other is low, rather than both being low in the same population (17). DISCUSSION Between 1967 and 1975. cancer incidence in Utah was significantly below that of the United States as estimated by both the TNSC and the SEEK Program (19). Virt~ually all of this difference is attributable to the lower rates in the Mormon portion of the Utah population. Thi, difference may be real or an artifact o~ the case-ascertainment procedure~ of the Utah Can- cer Registry and/or the matching pro~'dure~ used to ascertain religion. The R~gistry has gathered data throughout the State since 1966 and, since 1973, it has been a pard.dpant in the SEEK Program. Cancer cases were usually identi- fied by. the $8 hospitals in the State, but additional annual searches were made of the 21 pathology Inborn- JNCL VOL. ~. NO. 5. NOVEMaER T109371651

1058 Lyon, Gardner. m~d We~ I I I I I I ! ! 0 LIP I f ! t I I ! ! ! ! o cIrRYI X II~IIIII~NIJ)I ~N~D! I MELANOMA STOMACH COLON- ~ECTUN M~ANQMA STOMACH PANCREAS NECTUM ! I I ! NLO$ T~x:r.~GUR~.S I-4.----31R for sek.c~ed cancer sites by rcli[ion ;nd sex, utah, ]967-75, LDS=Mormon; NLDS=non.Mormon. torics and 2 radiation therapy centers serving the Share. AI! death certificates with mention of .cancer are routinely forwarded to the Registry. For this period, only 5.L~ of all cancers were ascertained with the death certificate as the sole source. A l-year survey of the records of these decedents revealed d~.¢ most of them were elderly individuals who were diagnosed and treated in doctors' o[fices or in nursing homes. O.m-of-state diagnosis and treatment do not represent a serious problem in Utah, with an average of four to five cases located out of state annually. We have no reason to suppose that a Mormon would be less likely to be identified and diagnosed with cancer than a non- Mormon. In fact, cancers of unknown sites were significantly more likely in the non-Mormons than in the Mormons. The cenu'al Church files used for identification of membership contained approximately 5.5 million rec- ords a~ the time of this study. The file of living members was computerized in 1975 and has trans- JNcI. g'OL. ~..-N'O. 5..~01rF.M~Eg 1900 T109371652

ICD eerie M~e Femzle M~e Female 140 ~p 11.~ ~ 0~ 26 l~ M 1~ 141 To~e 1~ ~1 0.~ lS &~ 46 1.78 I~ G~m a~ mou~ 1.01 ~ 0,~ 16 ~.~ ~ ~1 147 N~,x 0~ 14 0.~ 9 0,~ S 0,~9 I46, 1~149 O~er pha~x LIT ~ 0~ 8 &01 38 .0~ IS0 ~ I~ 42 0~ T 4.~ ST I.~ 152 S~ll in.fine 0.~ ~ 0.74 ~ 1.~ 13 1.18 15 l~ ~l~ 21.~ ~9 18,~ ~2 2818 311 30.~ 372 1~ ~m 11.~ 257 7.70 2~ 12.14 1~ 9.75 1~.0 ~ver 1.~ 32 0.~ 21 1.~ 18 0.78 10 1~.0 ~llb~dder ~ ~ 1.~ ~ 1.~ 15 2.51 1~6.1. 156.1- ~her bilia~ p~ 1~ 28 1~ 31 0.~ 10 0.~ 11 1~.9 167 P~e~ 8.47 1~ 4.17 1~ 9.~ 108 7.~ 1~1~ ~er di~fi~ or~ 0.71 18 0~ 26 0.~ 8 0.~ 8 161 ~x 3.~ ~ 0.~ 10 9.~ 118 1.27 1~ Lung ~.~ ~ 4.71 137 ~8.~ ~ 10.74 1~, 1~ O~er mpi~WW ~ 1.~ ~ 0.~ 19 1.~ 27 1.~ 18 170 ~n~ ~ join~ 1.14 41 0.~ 19 1.49 19 0.~ 171 S~ fi~u~ 2.19 ~ 1.~ ~ 3.71 46 2.57 1~ S~n, ~l~m 5.~ I~ 5.~ I~ 7.~ 89 8.5 ~ [ 1 174 B~t 0.73 17 61~ 1.7~ 0.~ 9 ~.~6 1,0~ In sire~ 1~.18 517 48.~ In~i~ 8.~ ~ 17.~ I~.0 Corp~ u~ri 21.19 ~ ~.40 1~.9 U~ HOSr L0I ~ 0.~ ll 1~,0 ~ I0.~ 3~ 14.75 1~.0 Va~na 0.17 5 0.7I 9 1~,~1~.3 VuI~ eli~s 0.75 ~ 1.69 181. I~.~ ~her fem~e genial 1.~ 33 1.~ 18 1~.9. s~m 1~,9 186 T~tia ~.~ ~ 3.74 1~.0 Penis 0.~ 7 0.78 , T 1~.1-187,9 Se~mm a~ o~er 0,~ 2 0,~ 0 ~e ~ni~l 1~ Bl~der le.~ ~0 4.46 1~ 24.10 ~ Z~ 1~.0 Kidney ~.~ 1~ 2.~ 77 7.~ 89 3.~ 1~.~I89.8 O~r urin~ o~n, 0.~ 14 0.~ l0 0,~ 10 0.~ 7 l~ ~e and orbi~ 1.~ ~ 0.~ 29 LIT 15 0.~ 13 ~91-1~ B~in a~ o~er 4,~ I~ 4.46 141 5.~ 71 4.~ ',,3 T~id ~knd I.~ ~7 ~,~ 182 1.~ ~ T.~ ~'q ~he~ e~rine glands 0~ 10 0.g4 I1 0.~ Y 0.~ 8 ~ph~ma aM ~ 7.~ I~ 4.~ 1~ 7.71 94 5.~ 74 tleul~ e*ll H~fkin~ d~m 4.31 I~ 1.~ 6~ 8.~ 49 4.~ ~her ~phom~ LT5 "~ 1.37 4~ L49 18 g.70 Mu!~ple meylomt 8.~ 78 g~ 66 ~ ~ 8.~0 Acu~ ~ph~c 1.~ ~ 1.18 46 1.~ ~ L~ le~e~u . ~nie ~ph~e ]e~ 2.~ 47 0.~ 28 3~ ~5 1.24 kemi~ ~er ~ph~e l~ 0.~ 8 0.17 5 0.~ 7 ~13 2 m~ ~er ~ le~emM 2,91 75 2~ 74 ~ ~ LS1 ~ber ¢~nie leukem~ 1.~ ~ 1,~ ~ 2.12 ~ L46 18 ~her ]e~emi~ 0.~ ~ 030 ~ 0.99 14 ~4~ 6 • Code numbers ~tre from the Internaficmal Cla~ifieatlon of s Site ~ not included in th, All sites" ¢ NOS=not otherwis* Di~J~e~ (Eifhth Revision). J.~cL vot_ e..xo. 5, NOVEMBER T109371653