INTRODUCTION It is difficult to profile the American Indian population, because there are 511 federally recognized tribes and villages, each of which has its own unique culture and history. This report must be considered a discussion of the "average American Indian," which of course does not exist, but we are limited by available data sources and space. The 1980 United States census identified a total of 1,364,033 American Indians and 278 American Indian reservations (excluding Alaska Natives) where approximately one-fourth of all American Indians lived in that year. The majority of Indian people (estimated 54 percent) live in urban areas; 46 percent live in rural and reservation areas. The American Indian population residing in historic areas and tribal trust lands of Oklahoma (excluding urban areas) numbered 116,000, comprising 9 percent of the total American Indian population. Generally, American Indians had a significantly lower median family income ($13,768) in 1979 than that for the entire country ($19,917). The income of American Indian families living on reservations ($9,924) was even lower. Twice as many American Indians (27.5 percent compared to 12.4 percent) lived at or below the poverty level in 1980 as the total population. Unemployment rates are very high: In comparison to unemployment rates for the entire country, the rate for all American Indians combined is twice as high, and over four times as high for Indians living on reservations. Fifty-six percent of all American Indians were high school graduates in 1980, as were 43 percent of reservation Indians and 66 percent of the total United States population. The median age of American Indians was 23.4, according to the 1980 census, which is almost seven years younger than the overall United States figure of 30.0. Indians living on reservations were even younger, with a median age of 19.7.

INTRODUCTION TO CANCER AS AN ISSUE AMONG AMERICAN INDIANS AND ALASKA NATIVES Cancer is a growing problem among American Indians and Alaska Natives. Unfortunately, both non-Native and First Nations peoples are less aware of the growing cancer dilemma than they are of alcohol, violence, diabetes, and other well-promoted and widely dispersed conditions within Native communities. In the second half of the twentieth century, cancer has become the leading cause of death for Alaska Native women and is the second leading cause of death among Alaska Native men. In fact, cancer is currently the third leading cause of death for all North American Natives5 and is the second leading cause of death among American Indians (both sexes) over age 45. The disease is the third most cited reason for hospital stays among Indian Health Service beneficiaries served by the Alaska Area Native Indian Health Service. Cancer rates, previously reported as less frequent in American Indian and Alaska Natives, have been increasing throughout the last twenty years. Incidence rates among Alaska Natives have exceeded “U.S. All Races” rates for most cancer sites. Rates are increasing similarly for Canadian bands. Within Native American communities, health programs continue to focus on alcoholism and diabetes, although cancer is responsible for more deaths than either of these conditions. Because the word cancer is not indigenous, it translates into some Native languages as “the disease for which there is no cure” or “the disease that eats the body.” Many tribes regard cancer as a white man’s disease because of its rarity before European contact. For many Native cancer patients, the disease is not discussed and is considered a form of punishment, shame, and guilt. A few tribes consider the patient’s suffering necessary in order to ensure the health of the other tribal members (they wear the pain so that their community will be spared). Some tribal members living with cancer—infected with the cancer spirit—are considered contagious and are ostracized by their communities. Other tribal members refuse cancer treatment surgery for fear that their body and spirit will be incomplete, leaving them incapable of finding their ancestors when they move to the other side (death).

INTRODUCTION Cigarette smoke is an equal opportunity killer. Although health data on American Indian populations are less comprehensive than desirable, it is clear that smoking-related diseases are a major cause of mortality. Because norms in the social environment are crucial in determining behaviors that lead to health or to illness, this paper reports data on policies that Indian agencies have implemented to regulate the personal use of tobacco products within their sites. Also reported are observations at Indian sites showing how policies are expressed.

Medically underserved populations in the United States continue to experience higher cancer burdens of incidence, mortality, and other cancer-related outcomes. It is imperative to understand how health inequities experienced by diverse population groups may contribute to our increasing unequal cancer burdens and disparate outcomes. The National Cancer Institute convened a diverse group of scientists to discuss research challenges and opportunities for cancer epidemiology in medically underserved and understudied populations. This report summarizes salient issues and discusses five recommendations from the group, including the next steps required to better examine and address cancer burden in the United States among our rapidly increasing diverse and understudied populations. Cancer Epidemiol Biomarkers Prev; 25(4); 573-80. ©2016 AACR SEE ALL ARTICLES IN THIS CEBP FOCUS SECTION, "MULTILEVEL APPROACHES TO ADDRESSING CANCER HEALTH DISPARITIES".