Rates of cancer incidence across terciles of the foreign-born population in Canada from 2001-2006.

Carriere, Gisele M. ; Sanmartin, Claudia ; Bryant, Heather 等

Understanding the potential impact of immigration trends on Canada's public health program needs is increasingly important. In 2006, an estimated 6.2 million immigrants comprised 19.8% of Canada's population, (1) and it is estimated that by 2031, 28% of Canada's population will be foreign-born. (2) Current evidence on cancer screening indicates lower rates of uptake among immigrant populations, potentially leading to delayed detection and increase in the risk of cancer-related deaths. (3-7) These risks may translate into increases in cancer (8) and cancer-related health service utilization. (9) Therefore, anticipating the relative cancer risks for this growing subpopulation is important. However, there are data challenges hindering our ability to fully understand the pattern of cancer risk among Canada's immigrant population.

Evidence to date suggests that, overall in Canada, immigrants and refugees experience lower risk for cancer generally (10,11) and lower risk of death caused by cancer. (12,13) However, these reduced risks may not extend to all cancers. Cohort-based research showed that, nationally, immigrants experience a higher risk for liver, nasopharynx and cervical cancers. (10) Furthermore, both cancer incidence and mortality risk can differ according to country of birth (10-19) and time since immigration so that, depending upon the cancer site and relative risk within country of origin, cancer risk may increase to approach risk similar to that of the host country, (19-23) or alternatively, decrease for some cancer sites in comparison to that within the host country. (22,23)

As the composition of Canada continues to change, (1) challenges to providing comparable information regarding patterns of cancer risk among immigrants at both the national and subnational level persist. Currently, information needed to track cancer incidence by foreign-born status is not available at the national level. The Canadian Cancer Registry does not consistently report place of birth for all provinces and territories. Studies have used record linkage to conduct cancer surveillance. (10,11) However, data are not routinely available to conduct national and comparable regional cancer surveillance by a person's foreign-born status in order to track incidence in this subpopulation. The objective of this study is to apply a standardized area-based measure to examine whether or not estimated cancer incidence rates among individuals living in given areas vary systematically according to the concentration of foreign-born individuals living in the same given areas. The presented results are relevant since this standardized measure extends previous work, and enables reporting of comparable subnational cancer incidence rates according to concentration of foreign-born population, in addition to the reported national rates. Furthermore, as the population composition changes over time, results obtained using this method remain relevant to future research that may continue to apply this publically accessible methodology to report changes over time to incident cancer according to a standardized measure of area concentration of foreign-born population.

METHODS

Data sources

Cancer incidence was calculated using 2001 to 2006 data from the national Canadian Cancer Registry (CCR), a dynamic, person-oriented, population-based database maintained by Statistics Canada. A file containing records of incident invasive cancer cases was created using the multiple primary coding rules of the International Agency for Research on Cancer (IARC). (24) Cancers were classified based on the International Classification of Diseases for Oncology, Third Edition (25) and grouped using Surveillance, Epidemiology, and End Results (SEER) Program grouping definitions (coding available upon request to author). (26) Non-melanoma skin cancers (basal and squamous) were not included. (27) Incident cancer counts were compiled using CCR postal codes that represented patients' usual place of residence at the time of tumour diagnosis. Incidence patterns for eighteen types of cancer were initially investigated; seven specific cancers were chosen for this report given their population incidence (lung, female breast, prostate, colorectal), and because distinctly reversed incidence patterns were noted for nasopharynx, liver, and thyroid compared to those found for other cancers.

In total, 895,838 records were extracted from the CCR from 2001 to 2006. Of those, 27,020 records were excluded (3%) due to missing or invalid postal code information, or because the postal code indicated an institutional address (e.g., hospitals) that was considered out-of-scope for the study population.

Canadian population estimates and area-based estimates of the foreign-born population, including nonpermanent residents, were taken from the 2006 Census (20% sample) weighted to represent the Canadian population. This socio-demographic information is aggregated and made available at the dissemination area (DA) level, representing the smallest areas for which census population characteristics data are disseminated. (28) Population counts by percentage foreign-born terciles are provided by region in the Appendix table.

Definition of Foreign-born

"Foreign-born" refers to those who either 1) ever held the legal status of immigrant to Canada, or 2) were a non-permanent resident (NPR). NPRs are people from another country who, at the time of the Census, held a work or study permit or were refugee claimants, or who had applied for landed immigrant status but had not yet been accepted, in addition to family members living with them in Canada. From a health perspective, NPRs more closely resemble immigrants than Canadian-born, so they were included in the foreign-born category. Everyone else was considered to be non-foreign-born.

The concentration of foreign-born was calculated using the 2006 Census (20% sample) data at the DA level (n = 50,214). The foreign-born percentage value was used to classify each DA into one of the following terciles: low foreign-born (tercile 1: <27.0% foreign-born); medium foreign-born (tercile 2: >27.0% to <51.8% foreign-born); and high foreign-born (tercile 3: >51.8% foreign-born). The rationale and methods used to establish the cut-off percentage values to define the terciles are described in detail elsewhere. (29) Note that there were no DAs with a high concentration of foreign-born in the Atlantic region.

Each cancer record was assigned a 2006 DA code based on postal code of patients' residence at time of diagnosis by using Statistics Canada's Postal Code Conversion File application (PCCF+) version 5F. (30) The DA code on the cancer record was then used to assign the foreign-born tercile information. This process allowed each incident cancer event to be classified as having occurred in an area with either a low, medium or high concentration of foreign-born (Appendix Table).

Analysis

Counts of incident cancers, pooled within 2001-2006, represented cancer incidence rate numerators. The 2006 Census dissemination area population estimates (including institutional residents) by age and sex were multiplied by six to estimate person-years at risk (the incidence rate denominator). Rates were calculated per 100,000 population, with the exceptions of nasopharynx, liver and thyroid cancers which were calculated per million population. Rates were standardized using the direct method to the age and sex structure of the 2006 national population within all low foreign-born category areas (tercile l). The following four categories of age-specific rates were used to produce age-standardized results: <60 years, 60-69, 70-79 and >80. Standard errors used to compute 95% confidence intervals for age-standardized incidence rates (ASIR) were derived using methods published by the International Agency for Research on Cancer (IARC). (31) Confidence intervals for small counts (<50) used methods from Fay and Feuer. (32) Incidence Rate Ratios (IRR) represent comparisons of cancer rates of terciles 2 and 3 to that for the reference rate, tercile 1. Comparisons were conducted across terciles nationally, and within each of the five regions. In the computation of IRR, denominators were the rates of the reference group (tercile 1), numerators were those of terciles 2 or 3; corresponding standard errors were used to calculate confidence intervals to these ratios.

RESULTS

National cancer incidence patterns

At the national level (Table 1), the standardized incidence rates for all cancer sites combined were significantly lower among individuals living in areas with medium or high concentration of foreign-born population (ASIR = 447 and 388 per 100,000 population, respectively) compared to areas that had a low concentration of foreign-born population (ASIR = 493). Systematic variation in incidence according to concentration for foreign-born areas is apparent from resulting incident rate ratios (IRR = 0.91, IRR = 0.79 for medium and high concentration foreign-born areas, respectively). Lung, female breast, prostate and colorectal cancer incidence rates followed a similar pattern of variation, as did the sex-specific rates for lung and colorectal cancer (Table 2 for males, Table 3 for females).

However, not all cancers followed this pattern. The ASIRs and IRRs for cancers of the nasopharynx, liver and thyroid show an inverse association in which incidence rates were significantly elevated within high (tercile 3) and medium (tercile 2) concentration foreign-born populated areas compared to areas with low concentration foreign-born. The IRRs for these cancers within tercile 3 were 4.20, 2.00 and 1.81, respectively, and for tercile 2, 1.83 (nasopharynx), 1.51 (liver), and 1.42 (thyroid). These significantly different, inverse patterns for these cancers persisted for both males and females.

Regional cancer incidence patterns

At the regional level (Table 1), significantly lower colorectal cancer incidence rates occurred within tercile 3 compared to tercile 1 (Prairies IRR = 0.63, Ontario IRR = 0.75, Quebec IRR = 0.83, British Columbia IRR = 0.84). For female breast cancer (Table 3), significantly lower incidence rates occurred within tercile 3 areas compared to tercile 1 for the Prairie regions (IRR = 0.71), Ontario and British Columbia (IRR = 0.79), and Quebec (IRR = 0.82). Significantly lower incidence for prostate cancer (Table 2) occurred within tercile 3 areas for the Prairie regions (IRR = 0.56), British Columbia (IRR = 0.74), Quebec (IRR = 0.77) and Ontario (IRR = 0.78). Lower lung cancer rates occurred within tercile 3 (Ontario IRR = 0.65, Quebec IRR = 0.66, British Columbia IRR = 0.70, Prairies IRR = 0.83). For discussion purposes, characteristics of overall populations who resided within geographical areas classified as % foreign-born terciles are presented in Table 4.

DISCUSSION

Cancer surveillance using an area-based approach can be used to report cancer rates among individuals living in areas with varying concentration of foreign-born populations according to a standard, hence comparable, concentration measure of this subpopulation. Lower incidence occurred generally for areas with a high versus low concentration of foreign-born population. These findings extend the work of others (10) by providing subnational analyses and are consistent with individual-level based analyses which also found lower rates of most cancers among immigrant groups. (10-12) Exceptions to the reported pattern were found for liver, thyroid and nasopharynx cancers where more elevated incidence occurred within these same high concentration foreign-born areas. These national findings are similar to what had been reported for liver cancer using area-based information for Ontario. (33)

Lower cancer rates among areas with a high concentration of foreign-born may be partially explained by the composition of immigrants residing in these areas. There is great heterogeneity among Canadian immigrants within these areas, and health determinant behaviours likewise may vary greatly among immigrants according to place of birth. (16) Yet findings suggest that many of the source countries of immigrants to Canada, such as China, India, and the Philippines, (1) have lower incidence rates of cancer in general (15) by comparison to Canadian individuals. Furthermore, immigrants may carry reduced risk that may continue for several years following immigration. While the concentration of foreign-born from Asia for example, varies greatly across terciles, and across different regions (Table 4), higher concentrations of Asian foreign-born individuals who may carry reduced cancer risk (15) tended to be located primarily within tercile 3. For example, 37.7% of the population in tercile 3 reported an Asian birthplace, compared to 1.9% in tercile 1. This may explain, in part, why reported ASIRs for all cancers, and by type, are generally lowest within the high concentration foreign-born tercile. According to international data, cancer incidence (all sites excluding non-melanoma skin cancer) among Asia's population was lower at 153.6 (per 100,000, age-standardized) compared to that for Canada (296.6). (15) Conversely, liver cancer incidence is reportedly four times higher in Asian males (21.4 per 100,000) compared to Canadian males (5.2 per 100,000). (15) Differential cancer risk exposure in the birth country may explain, in part, the elevated ASIRs for liver cancer observed in areas with high compared to low concentrations of foreign-born individuals. Higher rates of liver cancer among Asian immigrant populations have been reported to be potentially associated with a greater prevalence of known liver cancer risk factors. (34,35) The presented trends may also suggest explanations for regional differences of cancer incidence observed in Canada. In particular, the results suggest an explanation for lower cancer rates generally among high foreign-born terciles in British Columbia and the Prairies. The more concentrated foreign-born populated areas for these regions are comprised of greater proportions of immigrants from Asia than were found in the concentrated foreign-born areas in Quebec, for example (Table 4). As stated, immigrants from Asia may carry comparatively less risk for cancer incidence in general. (15)

Differences in cancer rates derived using this area-based approach may partially be explained by variation in other population characteristics that are spatially distributed in similar ways. Since immigrants for the most part settle within urban areas, (1,36) rural populations are exclusively represented within low or medium foreign-born areas. It is possible, therefore, that differences in cancer rates among individuals living in areas with high versus low concentration foreign-born partially reflect health differences between rural and urban populations. Rural populations experience increased prevalence for smoking behaviours, (37,38) overweight or obese, (38) which are recognized risk factors for some cancers. (39) Population research has shown that Canada's immigrants are generally less likely to smoke. (40) If foreign-born persons are less likely to access primary care, or to participate in cancer screening, as mentioned, then this may have partly contributed to decreased detection of cancer incidence in these areas. Finally, education levels also vary by foreign-born terciles with higher prevalence of post-secondary education among individuals living in areas having high and medium concentration of foreign-born (Table 4). Potential relationships between cancer incidence, education and concentration foreign-born population require further investigation. As well, in future, since national and provincial person-level information is not readily available to address the issue of comparative cancer risk among Canada's immigrant population, this area-based method provides a standardized surveillance tool that could be used to report changes to cancer incidence according to area foreign-born concentration over time.

This study has several limitations. This area-based analysis does not provide cancer incidence information about foreign-born persons per se, but instead, describes cancer events occurring within geographies populated by differing concentrations of foreign-born as determined by the 2006 Census. Rate denominators used 2006 population estimates and did not adjust for population growth over the reference period. Nor did denominators account for institutional population as rate numerators did, the likely impact of which may have been conservative estimation of incidence rates. Length of residence and age at immigration were not controlled for in this area-based analysis. Despite evidence to suggest foreign-born carry reduced incident cancer risk upon arrival, (15) risk may increase over time to the degree that risk among foreign-born individuals resembles that of the Canadian-born population, (19,22,23) possibly in particular with regard to risks for lung and colorectal cancers. Risk convergence for these cancers to host country has been observed for second-generation persons, and those who migrated at young ages. (41) If effects of reduced cancer risk are conferred by factors related to having been foreign-born, then had information been available to directly measure this at the individual level, the magnitude of variation in area cancer incidence according to concentration foreign-born could possibly be greater than these results suggest. Our results may demonstrate conservative differences since, even within high-concentration foreign-born areas, Canadian-born persons comprised 36% of the population, therefore reported ASIRs reflect composite cancer risks for both foreign- and non-foreign-born population groups. Any effects of reduced cancer risk among the foreign-born may have been attenuated accordingly. Area-based concentration of additional population characteristics known to be relevant to health, including percentage area low income and educational attainment, varied greatly across foreign-born terciles but were not adjusted for. These other unadjusted factors may operate as confounders. For example, prevalence for low income was greater for tercile 3 areas, therefore if low income was associated with increased cancer risk, this could confound any protective effects associated with increased concentration of foreign-born population. Information regarding cancer risk health behaviours, such as smoking status, was not available. The descriptive associations described are not interpreted as causal; an experimental methodology was not applied.

Population estimates adjusted for net undercount on the Census were not available for dissemination areas. The 2006 Census collected no information on the place of birth or foreign-born status of residents of institutional collective dwellings (such as nursing homes), therefore calculations to produce foreign-born percentages used to classify areas did not include the institutional population. Finally, interpretation of regional differences needs to consider that variations to registry reporting practices across the 13 provinces and territories may have contributed to a small extent to noted regional variation to cancer incidence. (42)

CONCLUSIONS

Application of an area-based method creates the opportunity for regular population cancer incidence surveillance to produce standardized cancer incidence estimates at national and regional levels among the foreign-born population. Results from this area-based analysis resemble incidence patterns previously produced using individual-level records and are interpreted as suggestive evidence of associations between the characteristic of living in an area with a high concentration of foreign-born and decreased cancer risk generally, with the reverse being the case for at least three specific cancers. This area-based method provides a surveillance tool that uses a standardized measure of foreign-born population concentration that could be used to report changes to cancer incidence according to area foreign-born concentration over time. The tool could also inform health services planning such as the development of public education planning regarding cancer screening as the Canadian population becomes increasingly diverse.

Appendix A. Population in 2006 * by tercile of the foreign-born
population, by sex, by province or region, Canada

                   Total        Low Foreign-born (tercile 1)

                      All          All         Males       Females

Population in 2006

Canada             31,169,185   22,097,060   10,841,655   11,255,405
Atlantic            2,274,315    2,263,740    1,097,640    1,166,100
Quebec              7,480,310    6,269,040    3,070,670    3,198,370
Ontario            12,077,010    6,814,775    3,334,985    3,479,790
Prairies            5,227,955    4,375,040    2,169,425    2,205,615
British Columbia    4,009,085    2,273,955    1,117,665    1,156,290

                   Medium Foreign-born (tercile 2)

                      All        Males      Females

Population in 2006

Canada             5,734,465   2,786,780   2,947,685
Atlantic              10,575        5060        5515
Quebec               906,290     435,645     470,645
Ontario            2,918,810   1,415,475   1,503,335
Prairies             798,685     395,585     403,100
British Columbia   1,100,105     535,015     565,090

                   High Foreign-born (tercile 3)

                      All        Males      Females

Population in 2006

Canada             3,337,660   1,619,380   1,718,280
Atlantic                 --          --          --
Quebec               304,980     147,800     157,180
Ontario            2,343,425   1,136,265   1,207,160
Prairies              54,230      27,295      26,935
British Columbia     635,025     308,020     327,005

* Counts include all ages. National figures include the
two northern territories and Nunavut.

--Not applicable, no high % foreign-born population
dissemination areas existed for this jurisdiction.
Source: 2006 Census (20% sample), Statistics Canada.

Acknowledgements: The authors acknowledge the importance of Canada's provincial and territorial cancer registrars who submit cancer records to Statistics Canada to compile the Canadian Cancer Registry. Canadian Partnership Against Cancer provided additional funding for this work.

Conflict of Interest: None to declare.

REFERENCES

(1.) Chui T, Tran K, Maheux H. Immigration in Canada: A Portrait of the Foreign-Born Population, 2006 Census, Census year 2006. Catalogue Number 97-557XIE. Ottawa, ON: Statistics Canada, 2007.

(2.) Malenfant EC, Lebel A, Martel L. Projections of the Diversity of the Canadian Population 2006 to 2031. Catalogue No. 91-551-X 2010. Ottawa: Statistics Canada, 2007.

(3.) Khadilkar A, Chen Y. Rates of cervical cancer screening associated with immigration status and number of years since immigration in Ontario, Canada. J Immigr Minor Health 2013;15(2):244-48.

(4.) Shields M, Wilkins K. An update on mammography use in Canada. Health Rep 2009;20(3):1-14.

(5.) Wilkins K, Shields M. Colorectal cancer testing in Canada-2008. Health Rep 2009;20(3):1-10.

(6.) Lofters AK, Gozdyra P, Lobb R. Using geographic methods to inform cancer screening interventions for South Asians in Ontario, Canada. BMC Public Health 2013;13(395) doi:10.1186/1471-2458-13-395. Available at: http://biomedcentral.com/1471-2458/13/395 (Accessed June 4, 2013).

(7.) Lofters AK, Moineddin R, Hwang SW, Glazier RH. Predictors of low cervical cancer screening among immigrant women in Ontario, Canada. BMC Women's Health 2011;11:20 doi:10.1186/1472-6874-11-20. Available at: http//biomedcentral.com/1472-6874/11/20 (Accessed June 4, 2013).

(8.) Ellison LF, Wilkins K. Canadian trends in cancer prevalence. Health Rep 2012;23(1):1-10.

(9.) Li D. Hospitalizations 2006-2008 in a British Columbia population-based cohort of three-year breast cancer survivors. Presentation to the 2013 Annual Conference of the Canadian Association for Health Services and Policy Research, Vancouver, BC, May 28, 2013.

(10.) McDermott S, DesMeules M, Lewis R, Gold J, Payne J, Lafrance B, et al. Cancer incidence among Canadian immigrants, 1980-1998: Results from a national cohort study. J Immigr Minor Health 2011;13:15-26.

(11.) DesMeules M, Gold J, Kazanjian A, Manuel D, Payne J, Vissanjee B, et al. New approaches to immigrant health assessment. Can J Public Health 2004;95(3):122-26.

(12.) Ng E. Longitudinal Health and Administrative Data Research Team. Insights Into the Healthy Immigrant Effect: Mortality by Period of Immigration and Place of Birth. Catalogue 82-622-X, No. 8. Ottawa: Statistics Canada, 2011.

(13.) Sheth T, Nair C, Nargundkhar M, Anand S, Yusuf S. Cardiovascular and cancer mortality among Canadians of European, south Asian and Chinese origin from 1979 to 1993: An analysis of 1.2 million deaths. CMAJ 1999;161(2):132-38.

(14.) McCracken M, Olsen M, Chen MS, Jemal A, Thun M, Cokkinides V, et al. Cancer incidence, mortality and associated risk factors among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese ethnicities. CA Cancer J Clin 2007;57(4):190-205.

(15.) Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008 v2.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 10 [Internet]. Lyon, France: International Agency for Research on Cancer, 2010. Available at: http://Globocan.iarc.fr (Accessed September 12, 2011).

(16.) Rotermann M. The impact of considering birthplace in analyses of immigrant health. Health Rep 2011;22(4):37-43.

(17.) Auluck A, Hislop G, Bajdik C, Poh C, Zhang L, Rosin M. Trends in oropharyngeal and oral cavity cancer incidence of human papillomavirus (HPV)related and HPV-unrelated sites in a multicultural population: The British Columbia experience. Cancer 2010;116(11):2635-44.

(18.) Wang ZJ, Ramcharan S, Love EJ. Cancer mortality of Chinese in Canada. Intl J Epidemiol 1989;18(1):17-21.

(19.) Luo W, Birkett NJ, Ugnat A-M, Mao Y. Cancer incidence patterns among Chinese immigrant populations in Alberta. J Immigr Health 2004;6(1):41-48.

(20.) Yavari P, Hislop TG, Bajdik C, Sadjadi A, Nouraie M, Babai M, Malekzadeh R. Comparison of cancer incidence in Iran and Iranian immigrants to British Columbia, Canada. Asian Pac J Cancer Prev 2006;7(1):86-90.

(21.) Hislop TG, Bajdik CD, Saroa SR, Yeole BB, Barroetavena MC. Cancer incidence in Indians from three areas: Delhi and Mumbai, India, and British Columbia, Canada. J Immigr Minor Health 2007;9(3):221-27.

(22.) Kliewer EV, Smith KR. Breast cancer mortality among immigrants in Australia and Canada. J Natl Cancer Inst 1995;87(15):1154-61.

(23.) Kliewer EV, Smith KR. Ovarian cancer mortality among immigrants in Australia and Canada. Cancer Epidemiol Biomarkers Prev 1995;4:453-58.

(24.) Parkin DM, Chen VW, Ferlay J, Galceran J, Storm HH, Whelan SL. Comparability and Quality Control in Cancer Registration (IARC Technical Report No.19). Lyon, France: IARC, World Health Organization and International Association of Cancer Registries, 1994.

(25.) Fritz A, Percy C, Jack A, Shanmugaratnam K, Sobin L, Parkin DM, Whelan S, Eds. International Classification of Diseases for Oncology, Third Edition. Geneva, Switzerland: WHO, 2000.

(26.) Horner MJ, Ries LAG, Krapcho M, Neyman N, Aminou R, Howlader N, et al. SEER Cancer Statistics Review, 1975-2006. Bethesda, MD: National Cancer Institute. Based on November 2008 SEER data submission, posted to SEER website, 2009. Available at: http://seer.cancer.gov/csr/1975_2006/ (Accessed June 15, 2012).

(27.) Canadian Cancer Registry System Guide - 2007 Edition. Catalogue No. 82-225 X. Ottawa: Health Statistics Division, Statistics Canada, 2008.

(28.) Statistics Canada. Profiles for Canada, Provinces, Territories, Census Divisions, Census Subdivisions and Dissemination Areas, 2006 Census. Catalogue 94581-XCB2006. Ottawa: Statistics Canada, 2008.

(29.) Carriere G, Peters PA, Sanmartin C. Area-based methods to calculate hospitalization rates for the foreign-born population in Canada, 2005/2006. Health Rep 2012;23(3):43-51.

(30.) Wilkins R, Khan S. PCCF + Version 5F User's Guide. Catalogue No. 82F0086XDB. Ottawa: Statistics Canada, 2011. Available at: http://abacus.library.ubc.ca/bitstream/10573/42442/3/msword.pccf5f.pdf (Accessed June 9, 2011).

(31.) Esteve J, Benhamou E, Raymond L, Eds. Statistical Methods in Cancer Research, Volume IV, Descriptive Epidemiology. Lyon: International Agency for Research on Cancer, IARC Scientific Publications No. 128, 1994.

(32.) Fay MP, Feuer EJ. Confidence intervals for directly standardized rates: A method based on the gamma distribution. Stat Med 1997;16(7):791-801.

(33.) Chen Y, Yi Q, Mao Y. Cluster of liver cancer and immigration: A geographic analysis of incidence data for Ontario 1998-2002. Int J Health Geogr 2008;7(28); doi:10.1186/1476-072X-7-28.

(34.) Merican I, Guan R, Amarapuka D, Alexander M, Chutaputti A, Chien R, et al. Chronic hepatitis B virus in Asian countries. J Gastroenterol Hepatol 2000;15(12):1356-61.

(35.) El-Serag HB, Davila JA, Petersen NJ, McGlynn KA. The continuing increase in the incidence of hepatocellular carcinoma in the United States: An update. Ann Intern Med 2003;139:817-23.

(36.) Beshiri R, He J. Immigrants in Rural Canada: 2006. Rural and Small Town Canada Analysis Bulletin; Vol. 8, No. 2. Catalogue number 21-006-X. Ottawa: Statistics Canada, 2009.

(37.) Mitura V, Bollman RD. The Health of Rural Canadians: A Rural-Urban Comparison of Health Indicators. Rural and Small Town Canada Analysis Bulletin; Vol. 4, No.6. Catalogue 21-006-XIE2002006. Ottawa: Statistics Canada, 2003.

(38.) Canadian Partnership Against Cancer. Population Health in Canada's Largest Cities: A Cancer System Performance Spotlight Report. Toronto, ON: Canadian Partnership Against Cancer, 2013. Available at: http://www.cancerview.ca/systemperformancereport. (Accessed September 30, 2013).

(39.) Li FX, Robson PJ, Chen Y, Qiu Z, Lo Siou G, Bryant HE. Prevalence, trend and sociodemographic association of five modifiable lifestyle risk factors for cancer in Alberta and Canada. Cancer Causes Control 2009;20(3):395-407; doi 10.1007/s10552-008-9254-2.

(40.) Perez CE. Health status and health behaviours among immigrants. Health Rep 2002;13(Suppl.):1-13.

(41.) Stirbu I, Kunst AE, Vlems FA, Visser O, Bos V, Deville W, et al. Cancer mortality rates among first and second generation migrants in the Netherlands: Convergence toward the rates of native Dutch population. Int J Cancer 2006;119(11):2665-72.

(42.) Canadian Cancer Society's Steering Committee on Cancer Statistics. Canadian Cancer Statistics 2012. Toronto: Canadian Cancer Society, 2012.

Received: February 20, 2013

Accepted: October 29, 2013

Gisele M. Carriere, MA, [1] Claudia Sanmartin, PhD, [1] Heather Bryant, MD, PhD, [2] Gina Lockwood, MMath [3]

Author Affiliations

[1.] Health Analysis Division, Statistics Canada, Ottawa, ON

[2.] Vice President, Canadian Partnership Against Cancer, Toronto, ON

[3.] Manager, Analytics and Surveillance and Senior Biostatistician, Canadian Partnership Against Cancer, Toronto, ON

Correspondence: Gisele M. Carriere, Health Analysis Division, Statistics Canada, Room 600, Library Square Tower, 300 West Georgia Street, Vancouver, BC V6B 6C7, Tel: 604-666-5907, Fax: 604-666-6680, E-mail: [email protected]

Table 1. Standardized Cancer Incidence Rates (ASIR) * and
Incidence Rate Ratios (IRR) for Site-specific Cancers,
by Area Tercile for Percentage Foreign-born Population
From 2001 to 2006, Canada Overall, and by Region

Cancer Site                Area              Low % Foreign-born
                                          (tercile 1) ([dagger])

                                        # Cases   ASIR    95% CI

All sites                  Canada       653,990    493   492-494

                           Atlantic      71,929    516   512-520
                           Quebec       191,388    510   508-512

                           Ontario      203,895    493   491-496

                           Prairies     118,753    479   476-482

                           British       66,560    464   461-468
                             Columbia

Lung                       Canada        98,382     74     74-75

                           Atlantic      10,812     77     76-79
                           Quebec        34,471     92     91-93

                           Ontario       27,735     67     66-68

                           Prairies      15,618     64     63-65

                           British         9486     66     64-67
                             Columbia

Female Breast ([setion])   Canada        85,001    122   121-123

Colorectal                 Canada        84,812     64     64-64

                           Atlantic      10,292     74     72-75
                           Quebec        25,145     67     66-68

                           Ontario       26,280     63     63-64

                           Prairies      14,688     59     58-60

                           British         8156     57     55-58
                             Columbia

Prostate                   Canada        91,357    150   150-151

Nasopharynx ([parallel])   Canada           614      5       4-5

Liver ([parallel])         Canada          4434     33     32-34

Thyroid ([parallel])       Canada        11,346     86     84-87

Cancer Site                Area             Medium % Foreign-born
                                                (tercile 2)

                                        # Cases   ASIR    95% CI

All sites                  Canada       145,346    447   444-449

                           Atlantic         309    531   471-592
                           Quebec        26,885    476   471-482

                           Ontario       73,176    446   443-449

                           Prairies      16,302    427   420-433

                           British       28,674    435   430-440
                             Columbia

Lung                       Canada        18,164     57     56-57

                           Atlantic          44     77    59-100
                           Quebec          4051     72     69-74

                           Ontario         8509     53     52-54

                           Prairies        2049     57     54-59

                           British         3511     53     52-55
                             Columbia

Female Breast ([setion])   Canada        20,285    115   113-117

Colorectal                 Canada        18,001     56     55-57

                           Atlantic          39     68     51-90
                           Quebec          3531     62     60-64

                           Ontario         8953     55     54-56

                           Prairies        1928     52     50-55

                           British         3550     54     52-55
                             Columbia

Prostate                   Canada        20,242    141   139-143

Nasopharynx ([parallel])   Canada           283      8       7-9

Liver ([parallel])         Canada          1626     51     48-53

Thyroid ([parallel])       Canada          4181    122   118-125

Cancer Site                Area          Medium % Foreign-born
                                              (tercile 2)

                                              IRR      95% CI

All sites                  Canada            0.91   0.90-0.91
                                         ([double
                                         dagger])
                           Atlantic          1.03   0.92-1.15
                           Quebec            0.93   0.92-0.95
                                         ([double
                                         dagger])
                           Ontario           0.90   0.90-0.91
                                         ([double
                                         dagger])
                           Prairies          0.89   0.88-0.91
                                         ([double
                                         dagger])
                           British           0.94   0.93-0.95
                             Columbia    ([double
                                         dagger])
Lung                       Canada            0.76   0.75-0.77
                                         ([double
                                         dagger])
                           Atlantic          1.00   0.74-1.35
                           Quebec            0.78   0.75-0.80
                                        ([double
                                         dagger])
                           Ontario           0.79   0.77-0.81
                                         ([double
                                         dagger])
                           Prairies          0.89   0.85-0.93
                                         ([double
                                         dagger])
                           British           0.81   0.78-0.85
                             Columbia    ([double
                                         dagger])
Female Breast ([setion])   Canada            0.94   0.93-0.96
                                         ([double
                                         dagger])
Colorectal                 Canada            0.87   0.86-0.89
                                         ([double
                                         dagger])
                           Atlantic          0.93   0.68-1.28
                           Quebec            0.92   0.89-0.96
                                         ([double
                                         dagger])
                           Ontario           0.87   0.85-0.89
                                         ([double
                                         dagger])
                           Prairies          0.88   0.84-0.92
                                         ([double
                                         dagger])
                           British           0.95   0.91-0.99
                             Columbia    ([double
                                         dagger])
Prostate                   Canada            0.94   0.92-0.95
                                         ([double
                                         dagger])
Nasopharynx ([parallel])   Canada            1.83   1.59-2.11
                                         ([double
                                         dagger])
Liver ([parallel])         Canada            1.51   1.43-1.60
                                         ([double
                                         dagger])
Thyroid ([parallel])       Canada            1.42   1.37-1.47
                                         ([double
                                         dagger])

Cancer Site                Area              High %
                                          Foreign-born
                                           (tercile 3)

                                        # Cases   ASIR

All sites                  Canada        69,481    388

                           Atlantic          --     --
                           Quebec          7742    433

                           Ontario       47,739    389

                           Prairies         954    364

                           British       13,046    361
                             Columbia

Lung                       Canada          7935     46

                           Atlantic          --     --
                           Quebec          1076     61

                           Ontario         5086     43

                           Prairies         127     53

                           British         1646     46
                             Columbia

Female Breast ([setion])   Canada          9643     97

Colorectal                 Canada          8469     48

                           Atlantic          --     --
                           Quebec           999     56

                           Ontario         5680     48

                           Prairies          96     37

                           British         1694     47
                             Columbia

Prostate                   Canada          9323    121

Nasopharynx ([parallel])   Canada           378     19

Liver ([parallel])         Canada          1187     67

Thyroid ([parallel])       Canada          3089    155

Cancer Site                Area                High %
                                           Foreign-born
                                            (tercile 3)

                                         95% CI         IRR

All sites                  Canada       385-391        0.79
                                                   ([double
                                                   dagger])
                           Atlantic          --          --
                           Quebec       423-442        0.85
                                                   ([double
                                                   dagger])
                           Ontario      385-392        0.79
                                                   ([double
                                                   dagger])
                           Prairies     341-388        0.76
                                                   ([double
                                                   dagger])
                           British      355-367        0.78
                             Columbia              ([double
                                                   dagger])
Lung                       Canada         45-47        0.62
                                                  ([double
                                                   dagger])
                           Atlantic          --          --
                           Quebec         57-65        0.66
                                                   ([double
                                                   dagger])
                           Ontario        42-45        0.65
                                                   ([double
                                                   dagger])
                           Prairies       44-62        0.83
                                                   ([double
                                                   dagger])
                           British        44-48       0.70
                             Columbia              ([double
                                                   dagger])
Female Breast ([setion])   Canada         95-99        0.80
                                                   ([double
                                                   dagger])
Colorectal                 Canada         47-50        0.76
                                                   ([double
                                                   dagger])
                           Atlantic          --          --
                           Quebec         52-59        0.83
                                                   ([double
                                                   dagger])
                           Ontario        47-49        0.75
                                                   ([double
                                                   dagger])
                           Prairies       30-45        0.63
                                                   ([double
                                                   dagger])
                           British        45-50        0.84
                             Columbia              ([double
                                                   dagger])
Prostate                   Canada       118-123        0.80
                                                   ([double
                                                   dagger])
Nasopharynx ([parallel])   Canada         17-21        4.20
                                                   ([double
                                                   dagger])
Liver ([parallel])         Canada         63-71        2.00
                                                   ([double
                                                   dagger])
Thyroid ([parallel])       Canada       149-160        1.81
                                                   ([double
                                                   dagger])

Cancer Site                Area            High %
                                        Foreign-born
                                         (tercile 3)

                                              95% CI

All sites                  Canada          0.78-0.79

                           Atlantic               --
                           Quebec          0.83-0.87

                           Ontario         0.78-0.80

                           Prairies        0.71-0.81

                           British         0.76-0.79
                             Columbia

Lung                       Canada          0.60-0.63

                           Atlantic               --
                           Quebec          0.62-0.71

                           Ontario         0.63-0.67

                           Prairies        0.69-0.99

                           British         0.67-0.74
                             Columbia

Female Breast ([setion])   Canada          0.78-0.81

Colorectal                 Canada          0.74-0.77

                           Atlantic               --
                           Quebec          0.78-0.89

                           Ontario         0.73-0.78

                           Prairies        0.51-0.77

                           British         0.80-0.88
                             Columbia

Prostate                   Canada          0.79-0.82

Nasopharynx ([parallel])   Canada          3.69-4.78

Liver ([parallel])         Canada          1.88-2.14

Thyroid ([parallel])       Canada          1.74-1.88

* Age-standardized to the total 2006 population within the
low % foreign-born areas. Rates are expressed per 100,000
population, except for nasopharynx, liver, thyroid that are
reported per million population. Both sexes were combined
except for female breast and prostate. National figures
include northern territories, Nunavut.

([dagger]) Reference category.

([double dagger]) Significantly different compared to
reference category.

([section]) Sex-specific population denominators were used.
For breast cancer, figures are only shown for national
level. Figures for regions are shown in Table 3.

([parallel]) For prostate cancer, figures are only shown
for national level. Figures for regions are shown in
Table 2.

-- Not applicable, no high % foreign-born population
dissemination areas existed for this jurisdiction.

Sources: 2006 Census (20% sample), the Canadian Cancer
Registry, Statistics Canada.

Table 2. Standardized Cancer Incidence Rates (ASIR) * and
Incidence Rate Ratios (IRR) for Site-specific Cancers for
Males, by Area Tercile for Percentage Foreign-born Population
From 2001 to 2006, Canada Overall and by Region

Cancer Site               Area              Low % Foreign-born
                                          (tercile 1) ([dagger])

                                       # Cases   ASIR    95% CI

All sites                 Canada       345,065    571   569-573

                          Atlantic      38,933    615   609-621
                          Quebec        99,180    594   590-598

                          Ontario      107,370    566   562-569

                          Prairies      63,057    558   553-562

                          British       35,773    530   524-535
                            Columbia

Lung                      Canada        55,452     93     92-93

                          Atlantic        6360    101    99-104
                          Quebec        20,492    124   122-125

                          Ontario       15,129     80     79-82

                          Prairies        8351     75     74-77

                          British         4973     74     72-76
                            Columbia

Prostate                  Canada        91,357    150   150-151

                          Atlantic      10,517    164   160-167
                          Quebec        20,321    121   119-123

                          Ontario       31,574    165   164-167

                          Prairies      18,767    168   165-170

                          British       10,045    147   144-150
                            Columbia

Colorectal                Canada        45,962     77     76-77

                          Atlantic        5520     88     86-91
                          Quebec        13,512     81     80-83

                          Ontario       14,171     75     74-77

                          Prairies        8101     72     71-74

                          British         4513     67     65-69
                            Columbia

Nasopharynx ([section])   Canada           407      6       6-7

Liver ([section])         Canada          3330     55     53-56

Thyroid ([section])       Canada          2641     41     39-43

Cancer Site               Area             Medium % Foreign-born
                                               (tercile 2)

                                       # Cases   ASIR    95% CI

All sites                 Canada        73,805    510   507-514

                          Atlantic         153    623   523-723
                          Quebec        13,345    540   531-549

                          Ontario       37,190    509   504-514

                          Prairies        8254    495   484-506

                          British       14,863    499   491-507
                            Columbia

Lung                      Canada          9886     70     68-71

                          Atlantic          23     95    64-135
                          Quebec          2326     94     90-98

                          Ontario         4612     65     63-66

                          Prairies        1099     70     66-74

                          British         1826     62     59-65
                            Columbia

Prostate                  Canada        20,242    141   139-143

                          Atlantic          47    195   151-250
                          Quebec          2652    108   104-112

                          Ontario       10,893    151   148-153

                          Prairies        2300    142   136-148

                          British         4350    147   142-151
                            Columbia

Colorectal                Canada          9628     67     66-69

                          Atlantic          24     99    68-141
                          Quebec          1862     75     72-79

                          Ontario         4833     67     65-69

                          Prairies        1044     64     60-68

                          British         1865     63     60-66
                            Columbia

Nasopharynx ([section])   Canada           201     13     11-14

Liver ([section])         Canada          1199     80     76-85

Thyroid ([section])       Canada           905     56     52-59

Cancer Site               Area         Medium % Foreign-born
                                            (tercile 2)

                                            IRR      95% CI

All sites                 Canada           0.89   0.89-0.90
                                       ([double
                                       dagger])
                          Atlantic         1.01   0.86-1.19
                          Quebec          0.91    0.89-0.93
                                       ([double
                                       dagger])
                          Ontario          0.90   0.89-0.91
                                       ([double
                                       dagger])
                          Prairies         0.89   0.87-0.91
                                       ([double
                                       dagger])
                          British          0.94   0.92-0.96
                            Columbia   ([double
                                       dagger])
Lung                      Canada           0.75   0.74-0.77
                                       ([double
                                       dagger])
                          Atlantic         0.93   0.62-1.41
                          Quebec           0.76   0.73-0.79
                                       ([double
                                       dagger])
                          Ontario          0.81   0.78-0.83
                                       ([double
                                       dagger])
                          Prairies         0.93   0.87-0.99
                                       ([double
                                       dagger])
                          British          0.84   0.80-0.89
                            Columbia   ([double
                                       dagger])
Prostate                  Canada           0.94   0.92-0.95
                                       ([double
                                       dagger])
                          Atlantic         1.19   0.89-1.59
                          Quebec          0.89    0.85-0.93
                                       ([double
                                       dagger])
                          Ontario          0.91   0.89-0.93
                                       ([double
                                       dagger])
                          Prairies         0.85   0.81-0.89
                                       ([double
                                       dagger])
                          British          1.00   0.96-1.03
                            Columbia

Colorectal                Canada           0.88   0.86-0.90
                                       ([double
                                       dagger])
                          Atlantic         1.12   0.75-1.68
                          Quebec           0.92   0.88-0.97
                                       ([double
                                       dagger])
                          Ontario          0.89   0.86-0.92
                                       ([double
                                       dagger])
                          Prairies         0.88   0.82-0.94
                                       ([double
                                       dagger])
                          British          0.94   0.89-0.99
                            Columbia   ([double
                                       dagger])
Nasopharynx ([section])   Canada           1.98   1.67-2.34
                                       ([double
                                       dagger])
Liver ([section])         Canada           1.47   1.38-1.57
                                       ([double
                                       dagger])
Thyroid ([section])       Canada           1.36   1.26-1.46
                                       ([double
                                       dagger])

Cancer Site               Area              High %
                                        Foreign-born
                                         (tercile 3)

                                       # Cases   ASIR

All sites                 Canada        34,604    439

                          Atlantic          --     --
                          Quebec          3787    495

                          Ontario       23,706    439

                          Prairies         496    419

                          British         6615    409
                            Columbia

Lung                      Canada          4589     60

                          Atlantic          --     --
                          Quebec           650     85

                          Ontario         2960     57

                          Prairies          74     68

                          British          905     57
                            Columbia

Prostate                  Canada          9323    121

                          Atlantic          --     --
                          Quebec           697     93

                          Ontario         6789    128

                          Prairies         109     93

                          British         1728    109
                            Columbia

Colorectal                Canada          4462     57

                          Atlantic          --     --
                          Quebec           517     69

                          Ontario         2999     57

                          Prairies          49     42

                          British          897     56
                            Columbia

Nasopharynx ([section])   Canada           267     28

Liver ([section])         Canada           883    107

Thyroid ([section])       Canada           577     62

Cancer Site               Area                High %
                                           Foreign-born
                                           (tercile 3)

                                        95% CI        IRR

All sites                 Canada       434-444       0.77
                                                 ([double
                                                 dagger])
                          Atlantic          --         --
                          Quebec       479-511       0.83
                                                 ([double
                                                 dagger])
                          Ontario      433-445       0.78
                                                 ([double
                                                 dagger])
                          Prairies     381-457       0.75
                                                 ([double
                                                 dagger])
                          British      399-419       0.77
                            Columbia             ([double
                                                 dagger])
Lung                      Canada         58-62       0.65
                                                 ([double
                                                 dagger])
                          Atlantic          --         --
                          Quebec         78-92       0.69
                                                 ([double
                                                 dagger])
                          Ontario        55-59       0.71
                                                 ([double
                                                 dagger])
                          Prairies       52-83       0.90
                                                 ([double
                                                 dagger])
                          British        53-61       0.78
                            Columbia             ([double
                                                 dagger])
Prostate                  Canada       118-123       0.80
                                                 ([double
                                                 dagger])
                          Atlantic          --         --
                          Quebec        86-100       0.77
                                                 ([double
                                                 dagger])
                          Ontario      125-132       0.78
                                                 ([double
                                                 dagger])
                          Prairies      75-111       0.56
                                                 ([double
                                                 dagger])
                          British      104-114       0.74
                            Columbia             ([double
                                                 dagger])
Colorectal                Canada         56-59       0.75
                                                 ([double
                                                 dagger])
                          Atlantic          --         --
                          Quebec         63-74       0.84
                                                 ([double
                                                 dagger])
                          Ontario        54-59       0.75
                                                 ([double
                                                 dagger])
                          Prairies       32-54       0.58
                                                 ([double
                                                 dagger])
                          British        52-60       0.83
                            Columbia             ([double
                                                 dagger])
Nasopharynx ([section])   Canada         25-32       4.47
                                                 ([double
                                                 dagger])
Liver ([section])         Canada       100-115       1.97
                                                 ([double
                                                 dagger])
Thyroid ([section])       Canada         57-67       1.52
                                                 ([double
                                                 dagger])

Cancer Site               Area            High %
                                       Foreign-born
                                        (tercile 3)

                                             95% CI

All sites                 Canada          0.76-0.78

                          Atlantic               --
                          Quebec          0.81-0.86

                          Ontario         0.77-0.79

                          Prairies        0.69-0.82

                          British         0.75-0.79
                            Columbia

Lung                      Canada          0.63-0.67

                          Atlantic               --
                          Quebec          0.64-0.74

                          Ontario         0.68-0.74

                          Prairies        0.71-1.13

                          British         0.72-0.83
                            Columbia

Prostate                  Canada          0.79-0.82

                          Atlantic               --
                          Quebec          0.71-0.83

                          Ontario         0.76-0.80

                          Prairies        0.46-0.67

                          British         0.70-0.78
                            Columbia

Colorectal                Canada          0.73-0.77

                          Atlantic               --
                          Quebec          0.77-0.92

                          Ontario         0.72-0.78

                          Prairies        0.43-0.77

                          British         0.78-0.90
                            Columbia

Nasopharynx ([section])   Canada          3.80-5.20

Liver ([section])         Canada          1.83-2.12

Thyroid ([section])       Canada          1.38-1.66

* Age-standardized to the total 2006 population within the
low % foreign-born area. Rates are expressed per 100,000
population except for nasopharynx, liver, thyroid that are
reported per million population. Canada figures include the
two northern territories and Nunavut.

([dagger]) Reference category.

([double dagger]) Significantly different compared to
reference category.

([section]) Sex-specific population denominators were used.

-- Not applicable, no high % foreign-born population
dissemination areas existed for this jurisdiction.

Sources: 2006 Census (20% sample), the Canadian Cancer
Registry, Statistics Canada.

Table 3. Standardized Cancer Incidence Rates (ASIR) * and
Incidence Rate Ratios (IRR) for Site-specific Cancers for
Females, by Area Tercile for Percentage Foreign-born
Population From 2001 to 2006, Canada Overall and by Region

Cancer Site     Area                 Low % Foreign-born
                                   (tercile 1) ([dagger])

                                   # Cases   ASIR    95% CI

All sites       Canada             308,925    436   434-438
                Atlantic            32,996    440   435-445
                Quebec              92,208    451   448-454
                Ontario             96,525    439   436-442
                Prairies            55,696    421   418-425
                British Columbia    30,787    416   412-421
Lung            Canada              42,930     61     60-61
                Atlantic              4452     59     57-61
                Quebec              13,979     68     67-69
                Ontario             12,606     57     56-58
                Prairies              7267     56     55-57
                British Columbia      4513     60     59-62
Female breast   Canada              85,001    122   121-123
  ([section])   Atlantic              8903    121   119-124
                Quebec              25,293    127   125-128
                Ontario             26,620    124   122-125
                Prairies            15,372    118   116-119
                British Columbia      8599    119   116-121
Colorectal      Canada              38,850     53     53-54
                Atlantic              4772     61     59-63
                Quebec              11,633     55     54-56
                Ontario             12,109     53     52-54
                Prairies              6587     49     48-50
                British Columbia      3643     48     46-49
Nasopharynx     Canada                 207      3       3-3
  ([section])
Liver           Canada                1104     15     14-16
  ([section])
Thyroid         Canada                8705    129   127-132
  ([section])

Cancer Site     Area                 Medium % Foreign-born
                                          (tercile 2)

                                   # Cases   ASIR    95% CI

All sites       Canada              71,541    400   397-403
                Atlantic               156    456   384-529
                Quebec              13,540    432   425-440
                Ontario             35,986    400   396-404
                Prairies              8048    376   367-384
                British Columbia    13,811    387   381-394
Lung            Canada                8278     46     45-47
                Atlantic                21     64     43-94
                Quebec                1725     54     52-57
                Ontario               3897     44     42-45
                Prairies               950     47     44-50
                British Columbia      1685     47     45-49
Female breast   Canada              20,285    115   113-117
  ([section])   Atlantic                41    122    92-159
                Quebec                3643    121   117-125
                Ontario             10,331    116   114-118
                Prairies              2305    106   102-110
                British Columbia      3965    114   111-118
Colorectal      Canada                8373     46     45-47
                Atlantic                15     39     24-62
                Quebec                1669     50     48-53
                Ontario               4120     45     44-46
                Prairies               884     43     40-45
                British Columbia      1685     46     43-48
Nasopharynx     Canada                  82      5       4-6
  ([section])
Liver           Canada                 427     24     21-26
  ([section])
Thyroid         Canada                3276    187   180-193
  ([section])

Cancer Site     Area               Medium % Foreign-born (tercile 2)

                                   IRR                        95% CI

All sites       Canada             0.92 ([double dagger])   0.91-0.92
                Atlantic           1.04 ([double dagger])   0.88-1.22
                Quebec             0.96 ([double dagger])   0.94-0.98
                Ontario            0.91 ([double dagger])   0.90-0.92
                Prairies           0.89 ([double dagger])   0.87-0.91
                British Columbia   0.93 ([double dagger])   0.91-0.95
Lung            Canada             0.77 ([double dagger])   0.75-0.79
                Atlantic           1.09                     0.70-1.68
                Quebec             0.80 ([double dagger])   0.76-0.84
                Ontario            0.76 ([double dagger])   0.74-0.79
                Prairies           0.84 ([double dagger])   0.78-0.90
                British Columbia   0.78 ([double dagger])   0.74-0.82
Female breast   Canada             0.94 ([double dagger])   0.93-0.96
  ([section])   Atlantic           1.01                     0.74-1.37
                Quebec             0.95 ([double dagger])   0.92-0.99
                Ontario            0.93 ([double dagger])   0.92-0.96
                Prairies           0.90 ([double dagger])   0.86-0.94
                British Columbia   0.96                     0.93-1.00
Colorectal      Canada             0.86 ([double dagger])   0.84-0.88
                Atlantic           0.64                     0.38-1.08
                Quebec             0.91 ([double dagger])   0.86-0.96
                Ontario            0.85 ([double dagger])   0.82-0.88
                Prairies           0.87 ([double dagger])   0.81-0.94
                British Columbia   0.95                     0.90-1.01
Nasopharynx     Canada             1.55 ([double dagger])   1.20-2.01
  ([section])
Liver           Canada             1.56 ([double dagger])   1.39-1.74
  ([section])
Thyroid         Canada             1.44 ([double dagger])   1.39-1.50
  ([section])

Cancer Site     Area               High % Foreign-born (tercile 3)

                                   # Cases   ASIR    95% CI

All sites       Canada              34,877    352   349-356
                Atlantic                --     --        --
                Quebec                3955    390   377-402
                Ontario             24,033    353   349-358
                Prairies               458    320   290-350
                British Columbia      6431    328   320-336
Lung            Canada                3346     34     33-36
                Atlantic                --     --        --
                Quebec                 426     41     37-45
                Ontario               2126     32     31-34
                Prairies                53     40     29-51
                British Columbia       741     38     35-41
Female breast   Canada                9643     97     95-99
  ([section])   Atlantic                --     --        --
                Quebec                1007    104    97-110
                Ontario               6701     98    95-100
                Prairies               120     83     68-98
                British Columbia      1815     94     90-98
Colorectal      Canada                4007     41     40-42
                Atlantic                --     --        --
                Quebec                 482     46     41-50
                Ontario               2681     40     39-42
                Prairies                47     33     25-42
                British Columbia       797     40     37-43
Nasopharynx     Canada                 111     11      9-13
  ([section])
Liver           Canada                 304     31     28-35
  ([section])
Thyroid         Canada                2512    246   236-255
  ([section])

Cancer Site     Area               High % Foreign-born (tercile 3)

                                   IRR                        95% CI

All sites       Canada             0.81 ([double dagger])   0.80-0.82
                Atlantic           --                             --
                Quebec             0.86 ([double dagger])   0.84-0.89
                Ontario            0.80 ([double dagger])   0.79-0.82
                Prairies           0.76 ([double dagger])   0.69-0.84
                British Columbia   0.79 ([double dagger])   0.77-0.81
Lung            Canada             0.57 ([double dagger])   0.55-0.59
                Atlantic           --                             --
                Quebec             0.61 ([double dagger])   0.55-0.67
                Ontario            0.57 ([double dagger])   0.54-0.59
                Prairies           0.72 ([double dagger])   0.55-0.95
                British Columbia   0.63 ([double dagger])   0.59-0.68
Female breast   Canada             0.80 ([double dagger])   0.78-0.81
  ([section])   Atlantic           --                             --
                Quebec             0.82 ([double dagger])   0.77-0.87
                Ontario            0.79 ([double dagger])   0.77-0.81
                Prairies           0.71 ([double dagger])   0.59-0.85
                British Columbia   0.79 ([double dagger])   0.75-0.83
Colorectal      Canada             0.77 ([double dagger])   0.74-0.79
                Atlantic           --                             --
                Quebec             0.83 ([double dagger])   0.75-0.91
                Ontario            0.76 ([double dagger])   0.73-0.79
                Prairies           0.68 ([double dagger])   0.50-0.91
                British Columbia   0.85 ([double dagger])   0.78-0.91
Nasopharynx     Canada             3.61 ([double dagger])   2.87-4.56
  ([section])
Liver           Canada             2.05 ([double dagger])   1.80-2.33
  ([section])
Thyroid         Canada             1.90 ([double dagger])   1.82-1.99
  ([section])

* Age-standardized to the total 2006 population within the low %
foreign-born area. Rates are expressed per 100,000 population,
except for nasopharynx, liver, thyroid that are reported per
million population.

Canada figures include the two northern territories and Nunavut.

([dagger]) Reference category.

([double dagger]) Significantly different compared to reference
category.

([section]) Sex-specific population denominators were used.

--Not applicable, no high % foreign-born population dissemination
areas existed for this jurisdiction. Sources: 2006 Census (20%
sample), the Canadian Cancer Registry, Statistics Canada.

Table 4. Area Population Characteristics by Tercile of the
Foreign-born Population, by Province or Region, Canada 2006

% Foreign-born Tercile              Canada   Atlantic   Quebec

                                             %

High foreign-born (tercile 3)
  Foreign-born                      63.8     --         62.5
  Recent immigrant/non-permanent    17.1     --         22.3
    resident
  Place of birth was Asia           37.7     --         24.4
  Place of birth was Europe         11.6     --         14.5
  Place of birth was Africa          3.5     --          9.2
  Low income after taxes            19.9     --         32.3
  Completed university degree       28.4     --         28.6
Medium foreign-born (tercile 2)
  Foreign-born                      37.6     35.3       37.7
  Recent immigrant/non-permanent     7.9     18.6        9.3
    resident
  Place of birth was Asia           14.8     12.9       10.0
  Place of birth was Europe         12.9      5.4       12.3
  Place of birth was Africa          2.4      1.2        5.4
  Low income after taxes            12.6     22.0       17.9
  Completed university degree       28.3     45.1       28.5
Low foreign-born (tercile 1)
  Foreign-born                       9.8      3.9        5.8
  Recent immigrant/non-permanent     1.5      0.8        1.4
    resident
  Place of birth was Asia            1.9      0.7        1.1
  Place of birth was Europe          5.2      1.7        2.4
  Place of birth was Africa          0.5      0.2        0.7
  Low income after taxes             7.4      8.1        8.8
  Completed university degree       17.2     15.1       16.4

% Foreign-born Tercile              Ontario   Prairies   British
                                                         Columbia

                                              %

High foreign-born (tercile 3)
  Foreign-born                      64.3      59.0       63.0
  Recent immigrant/non-permanent    16.8      23.2       15.3
    resident
  Place of birth was Asia           36.5      40.2       48.4
  Place of birth was Europe         12.7       4.1        6.7
  Place of birth was Africa          3.3       4.4        1.4
  Low income after taxes            18.0      18.4       21.9
  Completed university degree       28.3      28.7       28.7
Medium foreign-born (tercile 2)
  Foreign-born                      38.1      34.7       38.5
  Recent immigrant/non-permanent     6.9       9.8        7.9
    resident
  Place of birth was Asia           13.0      18.6       20.6
  Place of birth was Europe         15.5       7.8       10.3
  Place of birth was Africa          1.9       2.5        1.3
  Low income after taxes            10.8      12.1       13.8
  Completed university degree       29.0      24.7       28.4
Low foreign-born (tercile 1)
  Foreign-born                      13.3      10.5       14.9
  Recent immigrant/non-permanent     1.4       2.0        1.7
    resident
  Place of birth was Asia            2.1       2.7        3.1
  Place of birth was Europe          8.2       4.7        8.3
  Place of birth was Africa          0.4       0.5        0.4
  Low income after taxes             6.0       7.3        8.1
  Completed university degree       18.7      17.5       16.6

--Not applicable, no high % foreign-born population dissemination
areas existed within this jurisdiction.

Sources: 2006 Census (20% sample), Statistics Canada.