[CANCER RESEARCH 35,3507-3512,November1975]

Summary

The published studies of cancer of United States Jews arereviewed. Despite the lack of religious designation on deathcertificates, case reports, and census returns, a number ofindirect methods for measuring the problem have beendevised, which produce fairly consistent findings. In general, for American Jews, these show deficits in cancermortality, among males, for the buccal cavity and pharynxand prostate and, among females, for the breast, uterinecervix and corpus, and bladder. Excessesin mortality, notedfor both sexes, are esophagus, stomach, colon, pancreas,lymphomas, and leukemia and, in females, the lung and theovary.

The standardized mortality ratios for cancer of selectedsites for Russian-born residents of upstate New York, 1969through 1971, are presented as an indirect measure of theproblem in the United States Jews. Statistically significantexcesses were found in males for stomach and colon, with astriking deficit in cancer of the buccal cavity and pharynx.Among females, excesseswere noted for stomach, pancreas,and lung with a sharp deficit in the uterine cervix.

On the basis of the religious affiliation of the cemetery ofburial, estimates of the Jewish and non-Jewish componentsof the 800 deaths in Russian-born residents were determined. Expected deaths in these two subgroups by sex, foreach cancer site, were then calculated by use of thesite-specific proportionate mortality of upstate New Yorkfor these years. This revealed a significant excess amongJewish males for colon cancer, with a deficit in lung cancer,while among the non-Jewish male components stomachcancer mortality was the only site significantly in excess.Among Jewish females, stomach and lung cancers were inexcess, with a deficit in cancers of the breast and cervixuteri. In non-Jewish Russian-born females, the only sitesignificantly in excess was stomach, with breast cancershowing a deficit.

Introduction

The topic of cancer in United States Jews finds a place inthis symposium because of the well-known differences incancer incidence and mortality for certain sites among Jewsand the possibility that some special or unique socialcharacteristic, such as diet, might be associated with a

I Presented at the Conference on Nutrition in the Causation of Cancer,

May 19to 22, 1975,Key Biscayne,Fla. This studywassupportedin part byGrant CA 12707from the National Cancer Institute.

2 Presenter.

cancer excess or deficit and thus possibly shed light on theetiology of the disease. This may be a logical proposition,but it is fraught with methodological problems that tend tocomplicate the study of such hypotheses. It has not been thepractice in this country to record religious affiliationroutinely on case reports, death certificates, or populationcensus returns. Thus, the ingredients from which meaningfulmorbidity or mortality rates may be calculated are generallynot available. It is only in a few special situations that thenecessary data are obtainable through coincidental localpopulation surveys and the search of hospital or otherrecords, where the cancer experience among United StatesJews may be assessed. Furthermore, measurement of theprofile of pertinent Jewish characteristics, especially thediet, is handicapped by this same lack of a solid demographic base. Jews, particularly in the United States, are aheterogeneous group derived from a variety of contrastingenvironments. Acculturation to American ways has beenrapid: thus foreign and native-born Jews of succeedinggenerations frequently present sharply different styles oflife. These points of difference may, of course, offer thepossibility of studying contrasting groups of Jews, if theycan be clearly identified. This paper reviews briefly thepublished studies ofcancer in United States Jews and adds asmall upstate New York experience, derived from the studyof deaths in Russian immigrants.

Review

Aside from a number of clinical impressions, the systematic assessment of cancer in the Jews of this country had itsorigin in the early attempts to compare mortality experiencein the foreign-born with that of the native population.Initially, these efforts were restricted to total cancer mortality (4), and it was not until 1929 that Lombard and Doering(14) first presented an analysis of site-specific cancermortality among the foreign-born of Boston. They wereable to demonstrate apparently real differences in thefrequency of cancer of various sites among subgroups of theforeign-born population. These provocative findings werenot pursued further until renewed interest in the subjectdeveloped in the mid-l950's.

MacMahon and Koller (16), studying patients withleukemia diagnosed during the period 1943 to 1952 in whiteresidents of Brooklyn, showed that the leukemia incidencein the foreign-born was significantly higher than among thenative-born and that the high rates were probably accountedfor by the Russian-born component of the population. Thisobservation is germane to the topic being considered here,

NOVEMBER 1975 3507

Cancer in United States Jews'

Peter Greenwald, Robert F. Korns,2Philip C. Nasca, and Patricia E. WolfgangBureau of Cancer Control, New York State Department of Health. Albany, New York 12237.

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P. Greenwald et a!.

since the bulk of Russian-born residents were of Jewishorigin. Using affiliation of the cemetery of burial as anindex of religion, the authors then compared leukemiadeaths to a systematic sample of all deaths in the area andfound leukemia as a cause ofdeath in Jews twice as often asamong others. This difference was apparent in both sexes, atall ages, in both native and foreign-born populations.Haenszel and Hillhouse (9), as part of a study of the patternof regional variation in uterine cancer morbidity in theUnited States, showed for New York City that Jewishwomen had very low cervical cancer rates but uterinecorpus cancer rates not remarkably different from thenon-Jewish. These findings were based on a morbiditysurvey for this site coupled with estimates of the Jewish andnon-Jewish white populations derived from a sample of thepopulation studied by the Health Insurance Plan of GreaterNew York (3).

MacMahon ( I5) extended his earlier studies of leukemiain Jews to all sites, using New York City deaths for 1955,and subsequently Newill ( 18) broadened this to deal with thecancer deaths in white residents from 1953 to 1958. Themethod for estimating death rates by religious groups wasagain through religious preference of the decedents asindicated by cemetery of burial and through the samplepopulation survey cited above. Certain sites were lesscommon in the Jewish group: among males, cancers of thebuccal cavity and pharynx, esophagus, gallbladder, larynx,lung and bronchus, prostate, and other male genitalia; andamong females, cancer of the cervix uteri. Certain othersites were more common among Jews than among eitherCatholics or Protestants; sites in which this was true in bothsexes included colon, kidney, brain, thyroid, melanoma,reticulum cell sarcoma, lymphosarcoma, Hodgkin's disease,other lymphoma, multiple myeloma, and leukemia; amongmales cancer of the breast; and among females cancer of thestomach, liver (primary), and pancreas.

Graham et a!. (5) in an analysis of the Tn-StateLeukemia Study population were able to show no differenceamong child cases and controls in their religious and ethnicbackground; however, among adult cases and controls,Jews, Russians, and Poles all showed significantly elevatedrisks. In Russian-born Jews the risk was actually 5 timesthat of non-Jews born in the United States. The distributionof histological types of leukemia did not differ in Jewish andnon-Jewish cases, an observation of some significance, sinceprior studies of this population had shown that the excessrisk furnished by exposure to irradiation was limited tomyeloid leukemia. Furthermore, the excess risk observed inthe Russian-born and Jews was shown in both the irradiatedand nonirradiated population. The authors make the pointthat the order of risk seen in various study subgroupsseemed to relate directly to the degree of cultural similarlyto the Russian Jewish model.

Lung cancer mortality and morbidity in New York CityJewish males was the focus of papers by Seidman (19) andWynder and Mantel (23) both showing lower rates amongJewish than among Catholic or Protestant men. This was areversal of the 1931 findings of Bolduan and Weiner (2)which had indicated that Jews had a considerably higher

proportion of all cancer deaths attributable to lung cancer.Data on smoking habits and occupational exposures wereconsistent in showing cigarette smoking lowest in Jews andhighest in Catholics.

Haenszel (7) has presented a thoughtful review of theinternal consistency of the sources of data and findings in 3studies bearing on ethnic and religious differences in cancermortality. These included his own report on cancer mortality in migrants from the U.S.S.R., as of 1950 (6) laterupdated for the years 1959—61(17); MacMahon's (15) studyof the ethnic distribution of cancer mortality in New YorkCity in 1955, already cited; and Seidman's (20) large-scale,systematic analysis of New York City cancer mortality(1949 to 1951) for religious and socioeconomic groups. Despite differences in data source and methodology used,there was remarkable consistency in delineating above or below average risks among United States Jews. An addedfinding was that the male/female ratios of risk for Jews inthe United States were lower for most cancer sites, with atendency for the sex ratios to be displaced toward thatobserved in Israel. In general, the sex ratios of site-specificcancer risks for Jews in Israel and the United Statesdeviated less from unity than in other populations.

Cancer Mortality in Russian-born Residents

For the purposes of this presentation, it seemed useful toexamine the upstate New York cancer mortality in Russianimmigrants. Although this is a limited experience and theanalysis presents only an indirect measure of the problem inthe United States Jews, the exercise seemed worthwhilesince it represented a population and environment somewhat different from New York City, where the bulk ofstudies of cancer in Jews have been conducted. Furthermore, it would furnish a more recent appraisal of datacollected 2 decades after the 1950 material used by Haenszel(6) in his large-scale study of cancer mortality among theforeign-born in the United States and 10 years after theupdated unpublished analyses of the National Center forHealth Statistics (17).

Materials and Methods

Russian-born residents of New York State (exclusive ofNew York City), who died from a neoplasm (ICDA 8thRevision, Sites 140—239)during the years 1969 through197 1, were selected for study. Population counts of Russianborn residents of New York State by age and sex wereavailable from a special computer tape file recently obtainedupon special request from the United States Bureau of theCensus. This denominator file, which was derived from theassembled and edited 15% sample portion of the 1970Census, contains popalation counts for each county in NewYork Statebyage,sex,andcountryof origin.

SMR3 were calculated for malignant neoplasms of selected sites utilizing the files described above. Average

a The abbreviation used is: SMR, Standardized Mortality Ratios.

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Site (ICDA 8th Revision, 1965)No.

ofdeathsMalesFemalesObservedExpectedSM

RObservedExpectedSMRBuccalcavityandpharynx(l40-149)

Esophagus(I50)Stomach(l5l)Colon(l53)Rectum(154)Gallbladder(I56)Pancreas(157)Lung(162)Malignant melanoma (172)Breast(174)Cervixuteri(l80)Otheruterus(182)Ovary(183)Prostate(185)Bladder(l88)Otherurinary(l89)Lymphomas(200-203)Leukemias(204-207)3

14456720

32889

5

47259

152111.06

9.6223.4947.3218.854.1122.89108.67

2.30

48.6619.448.66

16.8913.1327a

146192a142―1067312282

217

97129104891604

6375715122840

439

28

15

66

18153.30

2.6813.9043.6911.886.4116.2018.93

1.7850.89

8.169.86

16.71

6.234.13

12.839.49121

224266―130126187173―2lla225

7724b8190

96145140158

Cancer in United States Jews

annual age, sex, and site-specific cancer mortality rates forNew York State (exclusive of New York City) during theyears 1969 through 1971 were applied to the correspondingsex and age segments of the Russian population in order tocalculate the expected number of deaths for each site. TheSMR were formed by dividing the observed number ofdeaths attributed to eachtype of cancer by the corresponding number of expected deaths. The observed number ofdeaths attributed to each type of cancer was assumed to bedistributed asa Poissonvariable. Significance factors, at the5 and 1% levels, for the ratio of an observed value of aPoisson variable to its expectation were obtained from thepublication by Bailar and Ederer (I).

The cancer mortality experience of the Jewish andnon-Jewish segments of the Russian-born population ofNew York State during the study period was also compared. Russian-born decedents were designated as Jewish ornon-Jewishbasedon the religious affiliation ofthe cemeteryof burial or the funeral home listed on the death certificate.Of the 800 Russian migrants available for study, 482 wereclassified as Jewish or non-Jewish according to the cemetery of burial, while 218were classified on the basisof thereligious affiliation of the funeral home. The religiousclassification of the cemeteries and funeral homes wascompleted by the Assistant Director of the New York StateDepartment of Health's Bureau of Funeral Directing. Onehundred decedents had been buried in nondenominationalcemeteries or could not be classified according to the funeralhome. The religious affiliation of 89 of these 100 decedentswas determined through a telephone survey of the hospitalswhere the deaths had occurred. The religious affiliation ofI 1 migrants who died at home remained unknown.

The lack of population data by country of nativity andreligious affiliation did not allow for direct calculation ofmortality rates. Comparisons of the mortality experience ofthe Jewish and non-Jewish Russian migrants with that ofthe native population were accomplished through use of theproportional mortality method. The relative frequencies ofspecific causes of death attributed to cancer among theJewish and non-Jewish Russian migrants were comparedwith expectednumbers basedon the cause-specificproportionate cancer mortality of all residents of New York State(exclusive of New York City) during the years 1969 through1971. An adaptation of the Mantel-Haenszel procedurewasused to compute continuity-corrected x2's with I degree offreedom (12). This procedure includes an adjustment forboth age and sex differences between the study and reference populations.

Results

The SMR of selected cancer sites among Russian-bornresidentsof upstateNew York (1969 to 1971)are presentedin Table 1. Although excessesor deficits are shown formany sites, the differences reach statistical significance foronly 3 of these among males (buccal cavity and pharynx,stomach, and colon) and for 4 among females (stomach,pancreas, lung, and cervix uteri). A comparison of thesefindings with those of Seidman (21) and Haenszel (6) isdisplayed in Table 2. In general, the SMR in the presentstudy are consistent with those found in the other 2 studies,based on deaths occurring around 1950. The remarkablylow SMR for cancer of the buccal cavity and pharynx

Table I

SMR for malignant neoplasms ofselected sites among Russian-born residentsof New York State,exclusive of New York City, 1969 to 1971

a SMR significantly different from 100 at 1% level.b SMR significantly different from 100 at 5% level.

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Site (ICDA 8th Revision, 1965)United

States―New York CitybNew YorkStateMaleFemaleMaleFemaleMaleFemaleBuccalcavityandpharynx(140—149)°39'6743d27'@121Esophagus(150)158―44@d78l79'@146224Stomach(151)187―210―110128―19?'266―Intestines(152-l53)'137―128―I20@117142―130Rectum(l54)11912090102106126Pancreas(157)140'163―117114122173―Lungandbronchus(162)l55@249―85d160―82211―Breast(174)78―8977Cervix

uteri ( I80)50―42'24'Otheruterus(182)57d7981Ovary(l83)

Prostate (185)68d130'791039790Bladder(188)Ill55'7612996Lymphomas(200-203)'141―177―116163―89140Leukemia(204-207)145―182―145―183―160158

P. Greenwald et a!.

Table 2

SMR for malignant neoplasms ofselected sites among migrants born in Russia: United States (35 states), 1950; New York City,1949 to 1951; New York State (exclusive of New York City), 1969 to 1971

a From Haenzel (6).b From Seidman (20).

C New York City data include larynx.

d SMR significantly different from 100 at 1% level.

e New York City and New York State data do not include the small intestine.

I SMR significantly different from 100 at 5% level.

g New York City data include the leukemias and lymphomas combined.

among males and the elevated ratios in both sexes for cancerof the stomach, intestines, and pancreas, although notalways reaching statistical significance, are very similar tothose reported in the earlier studies. The excess of deathsfrom cancer of the lung and bronchus in females and thelack of such excess in males is characteristic of recentstudies of lung cancer in United States Jews (19, 23) andagrees well with the distribution found by Seidman, illustrated in the table. The only other statistically significantdeviation noted in the presentstudy wasthe deficit in cancerofthe cervix uteri, with an SMR of24. Unfortunately, datesor ages of individuals at time of migration were notavailable.

The small numbers of deaths available for the remainingsites make further specific comment hazardous, although ingeneral, the SMR tended to follow the direction and sexpattern shown for the statistically signifcant findings ofHaenszel's much larger national study, used in comparison.In addition to the sites already mentioned, Haenszel foundsignificant excesses in the SMR for Russian-born males, forcancer of the esophagus, lymphomas, and leukemia; infemales for esophagus, ovary, lymphoma, and leukemia; butdeficits in males for prostate and in females for breast,uterine corpus, and bladder.

The ratio of observed to expected deaths for these samesites in Russian-born Jews and non-Jews is presented formales in Table 3 and for females in Table 4. The onlysignificant deviations noted among Jewish males are theexcess in colon cancer and deficit in lung cancer, whileamong non-Jewish males it is the excess mortality fromstomach cancer. Among Jewish females there are significant

excesses in stomach and lung cancer and deficits in cancersof the breast and cervix uteri, while non-Jewish femalesshow only an excess in stomach cancer and deficit in breastcancer.

These findings should, of course, be interpreted withcaution, in part for the following reasons: (a) the populationestimates for the Russian migrants are based on the 15%sample portion ofthe 1970 census and are, therefore, subjectto sampling errors; (b) a more critical problem arises fromthe lack of agreement concerning place of nativity as listedon the death certificate and as reported on the censusquestionnaire. Percentage of agreement for country oforigin between death certificate and matching census recordhas been reported by the National Center for HealthStatistics for whites who died in the United States fromMay to August 1960 (21). The level of agreement variedfrom a high of 100% for migrants from Norway to a low of77.9% for Austrian migrants. Decedents born in theU.S.S.R. demonstrated an 86.8% agreement, with Polandbeing the country most frequently involved in the misclassification of the Russian migrants; (c) finally, the comparison here of Jewish and non-Jewish Russian-born migrantsis based on indirect methods for assigning each decedent areligious affiliation and on the use of the proportionalmortality method, in lieu of direct calculation of mortalityrates.

Discussion

It is apparent that, despite the lack of routinely collectedinformation on religious affiliation in death certificates,

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Site (ICDA 8th Revision, 1965)Jewish

Russian-bornNon-JewishRussian-bornObserved

(0)Expected(E)X@O/EObservedExpectedX2O/EBuccalcavityandpharynx(I40-I49)27.523.502714.171.7724Esophagus(l50)86.600.1312163.571.08168Stomach(15l)2417.512.22137208.87I3.62b225Colon(l53)5635.8012.65―1561017.713.2656Rectum

(154)1313.970.029377.100.0299Gallbladder(l56)I2.910.703421.50l33Pancreas(157)1716.38104II8.580.46128Lung(162)5469.754.6V773539.550.5888Malignantmelanoma(l72)21.4314030.952.56316Prostate(l85)1818.55972939.973.3373Bladder(188)1515.349897.340.19123Otherurinary(189)75.840.0812023.280.1961Lymphomas(200-203)II11.100.029926.452.5631Leukemias(204-207)129.660.3712495.302.03170

Site (ICDA 8th Revision, 1965)Jewish

Russian-bornNon-JewishRussian-bornObservedExpectedx2

“O/EObservedExpectedx2O/EBuccalcavityandpharynx(l40-149)22.990.086721.130.12177Esophagus

(150)42.640.2915220.870.46230Stomach(151)2514.487.50―173Il4.279.64b258Colon(l53)4843.810.38110913.401.3667Rectum(154)1211.870.0110133.710.0181Gallbladder(l56)76.4010951.923.56260Pancreas(157)2015.820.9312685.051.27158Lung(162)3016.28ll.71b184106.691.28149Malignant

melanoma (172)21.730.03I1620.690.98290Breast(174)2944.536.27c651018.084.04c55Cervixuteri(180)I6.88439cISI3.030.8133Uterus(182)59.181.565433.130.0596Ovary(183)1114.510.677645.890.3568Bladder(l88)36.761.654431.850.23162Otherurinary(l89)63.950.631521.330.53Lymphomas(200-203)1511.880.6212624.360.8446Leukemias(204-207)109.260.0110843.39118

Cancer in United States Jews

Table 3

Observed and expected deaths due to selected cancer causes, with @‘values (Mantel-Haenszel test), among male Russian-born residents ofNew York State, exclusive of New York City, 1969 to 1971

a x@ < 0.01 not listed.bp < 0.01.Cp < 0.05.

Table 4

Observed and expected deaths due to selected cancer causes, with X2 values (Mantel-Haenszel test), among ftmale Russian-born residents QfNew York State, exclusive of New York City, 1969 to 1971

aXa < 0.01 not listed.bp < 0.01.Cp < 0.05.

case reports, and census returns, a number of alternative,indirect measures of cancer morbidity and mortality inUnited States Jews have been devised. Although the sourcesof data and methodology used differed, the findings reviewed here have been remarkably consistent.

There has been much speculation in the literature as tothe reasons for specific site excesses or deficits in cancermortality. It seems certain that no 1 Jewish characteristicwill account for all of the differences noted. Undoubtedly,different explanations account for many of the observed

elevations or deficits in mortality and morbidity. Unfortunately, in the present state of knowledge, none of thehypotheses proposed have led to definite proof of themechanisms involved. This is probably not the province ofepidemiology, but further refinement of data may be possible so as to focus the attention of the laboratory or others oncrucial elements in etiology.

For example, mortality from cancer of the buccal cavityand pharynx, thought to be related to smoking and alcoholconsumption, is markedly reduced in Jewish males. Evi

NOVEMBER 1975 3511

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P. Greenwa!d et a!.

dence ( 10) indicates that Jewish men smoke fewer cigarettesthan do Catholics or Protestants. Furthermore, there is awealth of documentation for the relative sobriety of Jews(22). A somewhat similar pattern is seen for cancer of theesophagus in the Jew, although this is not evident in theRussian immigrant data presented in Table 2. On the otherhand, Newell (18) showed a deficit in esophageal cancer inmale Jews based on the total resident Jewish population inNew York City.

Mortality from cancer of the lung and bronchus in maleUnited States Jews has apparently shifted, over time, froman excess in foreign-born to a significant deficit ( 19, 23).The reduced cigarette smoking, already cited, may furnish alogical explanation. Perhaps most striking, and receivingthe most attention of investigators, is the uniformly lowmortality from cancer of the cervix uteri in Jewish women.A number of social characteristics of thesewomen, including relatively high socioeconomic level and education, lateaverage age at marriage, lower fertility rates, and lesspremarital intercourse than in Catholics or Protestants ( I I),especially at ages under 20 years, fit in with current hypotheses suggesting a venereally transmitted infectiousagent as etiologically important.

The elevated mortality from leukemia and lymphoma inUnited States Jews has suggested that the excess may beattributable to greater exposure to diagnostic and therapeutic irradiation. Study of a probability sample of the population of Buffalo, N. Y. (13), confirmed that the Jewishpopulation showed appreciably greater exposure to suchirradiation than did Catholics or Protestants. However,Graham et a!. (5) suggest that other cultural factorsassociated with the Russian-born Jews, who show a 5-foldgreater risk than do native-born non-Jews, may be important. Their suggestion is supported by the finding of astepwise downward gradient of such excess risk as oneexamines other populations at progressively greater culturaldistance from the Russian-born Jew.

No mention has been made thus far about nutrition as animportant element in explaining the pattern of cancerincidence in American Jews. Certainly, such hypotheses aregermane to a number of sites, but with the meagerknowledge of the varied dietary habits of United StatesJews, it is difficult to formulate useful examples. Perhapsthe most attractive possibility relates to diet and coloncancer. In this instance, both male and female United StatesJews exhibit excessmortality for this site, and the impression exists that Jews in general, whether orthodox or not, eata diet rich in animal fat and protein. Sincepork is traditionally avoided, additional beef may make up the differenceand thus fit the proposal of Haenszel et a!. (8), basedonstudies in Hawaiian Japanese, that beef consumption is alikely contender for a role in etiology. On the other hand,hypothesesimplicating dietary fat may be equally or moretenable.

References

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2. Bolduan, C., and Weiner, L. Causes of Death among Jews in N. Y.City. New EngI. J. Med.. 208: 407-416, 1933.

3. Deardorif, N. R. The Religio-cultural BackgroundofNcw York City'sPopulation. Milbank Mem. Fund Quart., 33: 152- 160, 1955.

4. Dublin, L. I. Factors in American Mortality: A Study of Death RatesintheRace StocksofN. Y. State,1910.Am. Econ.Rev..6:523-548,1916.

5. Graham, S., Gibson, R., Lilienfeld, A., Schuman. L., and Levin, M.Religion and Ethnicity in Leukemia. Am. J. Public Health, 60:266-274, 1970.

6. Haenszel,W.CancerMortalityamongtheForeign-bornin theU. S.J.NatI. Cancer Inst., 26: 37-132, 1961.

7. Haenszel, W. Cancer Mortality among U. S. Jews. Israel J. Med. Sci.,7:1437-1450,1971.

8. Haenszel, W., Berg, J. W., Segi, M., Kurihara, M., and Locke. F. B.Large-BowelCancer in Hawaiian Japanese.J. NatI. Cancer Inst., 5!:1765-1779,1973.

9. Haenszel,W., and I-Iillhouse, M. Uterine-Cancer Morbidity in NewYork City andIts Relationto thePatternof RegionalVariationwithintheU. S.J.NatI.CancerInst.,22:1157-1181,1959.

10. Hammond, E. C., and Garfinkel, 1. Smoking Habits in Men andWomen. J. NatI. Cancer Inst., 27: 419-442, 1961.

I I. Kinsey, A. C., Pomeroy, W. B., Martin, C. E., and Gebhard, P. H.Sexual Behavior in the Human Female,p. 304. Philadelphia: W. B.Saunders.Co., 1953.

12. Li, F. P., Fraumini, J. F., Mantel, N., and Miller, R. W. CancerMortality among Chemists. J. Natl. Cancer Inst., 43. 1159- I 164,1969.

13. Lilienfeld, A. M. Frequency and Distribution of Diagnostic X-rayExaminations and Therapeutic Radiation in an Urban Population.Public Health Rept., 12: 1- 10, 1958.

14. Lombard, H. L., and Doering,C. R. CancerStudiesin Massachusetts.CancerMortality in Nativity Groups.J. Prey.Med., 3: 343-361, 1929.

15. MacMahon, B. The Ethnic Distribution ofCancer Mortality in N.Y.City, 1955. Acto Unio Intern. Contra Cancrum, 16: 1716- 1724, 1960.

16. MacMahon, B., and Koller, E. K. Ethnic Differencesin the Incidenceof Leukemia. Blood, 12: I - 10, 1957.

17. National Center for Health Statistics, Unpublished tabulations1959-1961.Cited by Haenszel(7).

18. Newill, V. A. Distribution of Cancer Mortality among EthnicSubgroupsofthe White PopulationofN. Y. City, 1953-1958.J. NatI.Cancerlnst.,26:405-417,1961.

19. Seidman, H. Lung Cancer among Jewish, Catholic and ProtestantMales in N. Y. City. Cancer, 19: 185-190, 1966.

20. Seidman, H. Cancer Death Rates by Site and Sex for Religious andSocioeconomic Groups in N. Y. City. Environ. Res., 3: 234-250, 1970.

21. Seidman, H. Cancer Mortality in N. Y. City for Country of Birth,Religions and Socioeconomic Groups. Environ. Res.. 4. 390-429,1971.

22. Snyder, C. R. Culture and Jewish Sobriety. In: M. Sklare (ed.), TheJews—Social Patterns of an American Groups, pp. 560-594. Glencoe,Ill.: The Free Press, 1968.

23. Wynder, E. L., and Mantel, N. Some Epidemiological Features ofLung Cancer among Jewish Males. Cancer, 19: 191- 195, 1966.

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