J Relig Health DOI 10.1007/s10943-014-9973-5 ORIGINAL PAPER
Lower Cancer Rates Among Druze Compared to Arab and Jewish Populations in Israel, 1999–2009 Iris Atzmon • Shai Linn • Boris A. Portnov • Elihu Richter Lital Keinan-Boker
•
Ó Springer Science+Business Media New York 2014
Abstract The Druze are a small ethnic minority in Israel amounting to about 130,000 residents (or 1.7 % of the total population of the country). Unlike other population groups, the Druze strive to keep their own traditions and marry mainly inside their own community. During the last decade, cancer morbidity among both Jews and Arabs in Israel has been increasing, while data on the Druze are little known and have not been analyzed and compared to other population groups to date. To compare cancer morbidity rates among Druze, Arabs and Jews in Israel during 1999–2009, gender-specific and age-standardized incidence rates of all site cancers and specific cancers of three population groups (Jews, Arabs and Druze) were received from the Israel National Cancer Registry for the period 1999–2009. Based on these rates, periodical incidence rates were calculated and mutually compared across the groups stratified by gender. As the analysis shows, the Druze had significantly lower cancer rates compared to both Arabs and Jews. Thus, for all site cancers, there were significantly higher cancer rates in Jewish males versus Druze males (RR = 1.39, 95 % CI = 1.16–1.65) and in Jewish females versus Druze females (RR = 1.53, 95 % CI = 1.27–1.85), but not statistically significant for Arab males versus Druze males (RR = 1.12 95 % CI = 0.93–1.35). Lung cancer rates in Arab males were
I. Atzmon (&) S. Linn L. Keinan-Boker School of Public Health, University of Haifa, Haifa, Israel e-mail:
[email protected] S. Linn Unit of Clinical Epidemiology, Rambam Medical Center, Haifa, Israel B. A. Portnov Department of Natural Resources and Environmental Management, Faculty of Management, University of Haifa, Haifa, Israel e-mail:
[email protected] E. Richter Unit of Occupational and Environmental Medicine, Hebrew University-Hadassah, Jerusalem, Israel L. Keinan-Boker Israel Center for Disease Control (ICDC), Ministry of Health, Ramat Gan, Israel
123
J Relig Health
also higher compared to Druze males (RR = 1.84, 95 % CI = 1.13–3.00). Jewish males had statistically significant higher rates of prostate cancer compared to Druze males (RR = 2.47, 95 % CI = 1.55–3.91). For thyroid and colon cancers, risks were not significantly different at the 95 % CI level; however, the risks were significantly different at the 90 % CI level (RR = 3.62, 90 % CI 1.20–11.02 and RR = 1.69, 90 % CI = 1.03–2.77, respectively). Jewish females had significantly higher rates of invasive breast cancer (RR = 2.25, 95 % CI = 1.55–3.25), in situ cervical cancer (RR = 4.01, 95 % CI = 1.27–12.66) and lung cancer (RR = 3.22, 95 % CI = 1.12–9.24) compared to Druze females. We thus observed lower cancer rates among Druze versus Arab and Jewish populations in Israel. A reason for these differences may be due to different nutritional habits. Druze still keep a less processed nutritional lifestyle, than is common in industrial society. There may also be other reasons that have not been identified yet. Keywords
Druze Cancer Smoking Consanguinity Incidence rates Israel
Introduction The Druze are a small ethnic minority in Israel, whose total population is about 130,000 people, or 1.7 % of the country’s some eight million people (http://www.cbs.gov.il/reader). The Druze are Arabic people in origin and mainly use the Arabic language in their daily life. They are well integrated into Israeli society and many of them serve in the army. On the one side, they participate in politics in close affiliation with the Jewish population and engage in the army. On the other side, they share the same language and cultural aspects with the Arab community. The Druze strive to maintain their traditional way of life and marry inside their own community, remaining outside of the ideological rift in the country (Nisan 2010). The Druze live in several towns and villages in the northern part of Israel, the largest of which are Daliat Il Carmel (population 15,000) and Yirka (population 14,800) (http://www.cbs.gov.il/reader). The Druze have no provision for the inclusion of anyone not born of two Druze parents (Nisan 2010). In the past, the main source of employment in the Druze community was agriculture (Ministry of Industry Commerce and Occupation 2005). However, during the last two decades, their employment in the agriculture sector gradually diminished (Ministry of Industry Commerce and Occupation 2005), while proportional shares of military service and employment in industry have gradually increased, thus exposing them to different lifestyles (Halabi 2002). Since the Druze rarely intermix with other population groups, the question about cancer incidence among the Druze is an interesting one, considering that cancer has become the leading cause of death in Israel in recent years (Goldberger et al. 2000). While cancer rates among the Arabs in Israel have been on the rise during the last decade (Israel National Cancer Registry), the trends among the Druze are less known. This study attempts to analyze, apparently for the first time, cancer incidence rates among the Druze population, and compare them to the Arab and Jewish populations living in Israel. In particular, this study aims at calculating cancer incidence rates of different cancers in the Druze versus Arabs and Jews, and to compare cancer rates of males versus females among each one of these ethnic groups.
123
J Relig Health
Methodology We conducted a retrospective cohort study. Age-standardized cancer incidence rates per 100,000 person years were obtained from the Israel National Cancer Registry (INCR) for the years 1999–2009, detailing males and females for Druze, Arabs and Jews. The Israel National Cancer Registry was established in 1960. Since 1982, it has been compulsory that all newly diagnosed cancers in the Israeli population be reported to this registry. Data collected by the Israel National Cancer Registry include demographic information (gender, date of birth, country of birth, date of immigration to Israel if applicable and date of death if applicable), date and location of cancer diagnosis, histological type of the malignant tumor and disease stage at diagnosis. Completeness of this registry for solid tumors is estimated at approximately 93 % (Fisher et al. 2003). Average incidence density per 100,000 person years (p-y) was calculated in each ethnic population stratified by gender. These rates were used for comparison of the different populations and genders. Incidence density is the measure for dynamic populations and for comparison with the cancer registry (Adami et al. 2002). Both the Israeli Population and the Israel National Cancer Registry are dynamic populations: people die and exit from the Israeli population or are born and added to the Israeli population; there are immigrants to Israel and emigrants from Israel. Rate ratios (RR) with 95 % and 90 % confidence intervals (95 % CI and 90 %) were calculated to compare cancer rates of all sites and specific cancer sites among Arabs versus Druze or Jews versus Druze. RR for each year was calculated comparing Arabs incidence rate/Druze incidence rate and Jews incidence rate/Druze incidence rate. We used Open Epi program to calculate the 95 % CI and 90 % CI for 100,000 p-y.
Results The study populations of Druze, Arabs and Jews, were followed for the period of 1999–2009. Rate results (Tables 1 and 2) are based on the number of cases presented in Table 3. The number of cancer patients each year in each one of the studied populations is presented in Table 4. Figures 1, 2 and 3 show time trends for 1999–2009 for all site cancers, prostate and cervix in situ. Figures 4, 5, 6, and 7 show time trends graphically for all site cancers. Comparison of cancer incidence rates in Druze versus other ethnic groups for males (Table 1), shows that incidence rates for all cancer sites for Druze males and females were significantly lower than the rates for Arabs or Jews. The RR for Arab males versus Druze males was not statistically significant (RR = 1.12, 95 % CI = 0.93–1.35), but it was statistically significantly higher for Jewish males versus Druze males (RR = 1.39, 95 % CI = 1.16–1.65). Among Arab males versus Druze males, there was a statistically significant higher rate of lung cancer (RR = 1.84, 95 % CI = 1.13–3.00). For Jewish males versus Druze males, there were statistically significant higher rates of prostate cancer (RR = 2.47, 95 % CI = 1.55–3.91). For thyroid and colon cancers, an increased risk was not found at the 95 % CI level but was statistically significant at the 90 % CI (RR = 3.62, 90 % CI = 1.19–11.02 and RR = 1.69, 90 % CI = 1.03–2.77, respectively).
123
123
0.45–2.62
1.21
0.26–5.520
0.91
0.33–2.50
0.76
Hodgkin’s
95 % CI
Larynx
95 % CI
Liver
1.09
Brain cancer
95 % CI
1.24
0.68–2.25
0.32–4.59
90 % CI
95 % CI
0.25–5.92
95 % CI
Bladder
1.22
0.53–5.77
95 % CI
Thyroid cancer
1.65
1.75
Kidney cancer
1.84
0.19–3.94
95 % CI
1.13–3.00
0.88
Cervix in situ
Lung cancer
0.35–5.51
95 % CI
95 % CI
1.38
Breast cancer in situ
1.18
0.55
0.20–1.91
0.62
0.24–5.30
1.13
0.46–2.64
1.10
0.79–2.51
1.41
1.19–11.02
0.96–13.63
3.62
0.69–2.01
0.69
0.02–51.05
1.37
0.18–3.71
0.82
0.35–1.86
0.81
0.18–5.35
0.98
0.71–3.31
0.61–3.84
1.53
0.76–6.91
2.29
0.30–9.13
0.20–4.64
95 % CI
0.95–8.62
0.97
Cervical cancer invasive
2.86
0.91–2.04
0.85–1.28
1.04
95 % CI
1.16–1.65
1.39
Female Arabs versus Druze
1.36
0.93–1.35
95 % CI
Male Jews versus Druze
Breast cancer invasive
1.12
All cancer sites RR
Male Arabs versus Druze
Table 1 Cancer rates among Arabs and Jews compared to Druze, in males and females 95 % CI and 90 % CI
0.71
0.04–54.13
1.55
0.20–3.86
0.87
0.52–2.41
1.12
0.45–8.46
1.95
0.90–3.96
0.78–4.56
1.88
1.12–9.24
3.22
0.73–15.71
3.38
1.27–12.66
4.01
0.94–10.57
3.16
0.41–6.61
1.65
1.55–3.25
2.25
1.27–1.85
1.53
Female Jews versus Druze
J Relig Health
1.62
0.47–5.57
0.80
0.34–1.88
0.80
0.35–1.79
0.75
0.36–1.55
1.22
0.72–2.06
1.01
0.52–1.95
0.58–1.75
1.28
0.51–3.21
95 % CI
Stomach
95 % CI
Leukemia
95 % CI
NHL
95 % CI
Prostate
95 % CI
Colon
95 % CI
90 % CI
Rectum
95 % CI
Bold values are statistically significant
0.22–2.64
Pancreas
Male Arabs versus Druze
95 % CI
Table 1 continued
0.69–3.97
1.65
1.03–2.77
0.94–3.05
1.69
1.55–3.91
2.47
0.46–1.81
0.91
0.32–1.69
0.74
0.37–2.00
0.86
0.63–6.77
2.07
0.14–2.17
Male Jews versus Druze
0.34–2.96
1.01
0.67–2.19
0.60–2.45
1.21
0.40–2.15
0.93
0.37–3.47
1.14
0.31–3.26
1.00
0.24–4.20
1.00
0.08–5.93
Female Arabs versus Druze
0.52–3.82
1.40
0.97–2.92
0.87–3.25
1.68
0.51–2.51
1.13
0.40–3.64
1.21
0.31–3.28
1.01
0.45–5.92
1.64
0.08–6.00
Female Jews versus Druze
J Relig Health
123
J Relig Health Table 2 Cancer rates among Druze, Arabs and Jews, 1999–2009, comparing rates in males vs females 95 % and 90 % CI Druze male versus female
Arabs male versus female
Jews male versus female
All cancer sites
1.21
1.30
1.09
95 % CI
0.99–1.47
1.07–1.58
0.93–1.29 1.71
Kidney cancer
2.02
2.15
95 % CI
0.39–10.51
0.60–7.66
0.68–4.30
Lung cancer
5.48
4.41
2.00
95 % CI
2.02–14.92
2.25–8.64
1.07–3.75
Thyroid cancer
0.37
0.30
0.71
95 % CI
0.09–1.47
0.09–0.99
0.32–1.60
Bladder
7.20
9.08
5.18
95 % CI
2.02–25.68
2.56–32.22
2.04–13.15
Brain cancer
0.78
1.05
0.76
95 % CI
0.33–1.81
0.44–2.50
0.34–1.71
Hodgkin’s
0.81
1.20
1.06
95 % CI
0.18–3.70
0.26–5.49
0.23–4.80
Larynx
15.9
10.59
6.34
95 % CI
0.91–279.20
0.89–126.6
0.57–70.09
90 % CI
1.44–176.4
1.32–84.99
0.84–47.73 2.20
Liver
2.83
3.14
95 % CI
0.57–14.03
0.47–21.17
0.31–15.77
Pancreas
1.08
1.75
1.37
95 % CI
0.27–4.41
0.49–6.20
0.48–3.88
Stomach
2.14
1.71
1.83
95 % CI
0.78–5.88
0.60–4.87
0.65–5.14
Leukemia
2.27
1.58
1.38
95 % CI
0.85–6.01
0.60–4.19
0.52–3.63
NHL
1.51
1.23
1.22
95 % CI
0.71–3.20
0.54–2.78
0.58–2.56
Colon
1.24
1.03
1.25
95 % CI
0.61–2.50
0.53–2.00
0.72–2.14
Rectum
1.22
1.55
1.44
95 % CI
0.43–3.43
0.58–4.14
0.62–3.34
Bold values are statistically significant
Comparison of Cancer Incidence Rates in Druze Versus Other Ethnic Groups for Females (Table 1) Differences in all site cancers incidence rates were statistically insignificant in Arab females compared to Druze females (RR = 1.04, 95 % CI = 0.85–1.28), but statistically significant for Jewish women compared to Druze women (RR = 1.53, 95 % CI = 1.27–1.85). Among Jewish females versus Druze females, there was a statistically significant higher rate of invasive breast cancer (RR = 2.25, 95 % CI = 1.55–3.25), in situ cervical cancer (RR = 4.01, 95 % CI = 1.27–12.66) and lung cancer (RR = 3.22, 95 % CI = 1.12–9.24).
123
94 77 30
Lung
Bladder
Larynx
2
12
20
264
848
1,661
Males
Females
Males
20
Lung
Arabs
22
In situ cervix cancer
638
168
1,661
1,002
9,237
Arabs males
Druze
190
Comparison between male versus female among Druze, Arabs and Jews
810
Colon
Invasive breast cancer
75
Thyroid
All site cancers
16
Lung
Druze females
94
Prostate
Comparison of number of cancer cases in Druze versus Arabs and Jews for males
899 96
All site cancers
Druze males
Comparison of number of cancer cases in Druze versus Arabs and Jews for males
24
104
287
Females
278
186
2,452
8,155
Arabs females
Table 3 Comparison of number of cancer cases in Druze versus Arabs and Jews for males, for females and for males versus females
1,493
9,684
10,816
Males
Jews
11,810
1,454
10,816
23,397
110,184
287
2,656
6,035
Females
6,035
4,482
35,930
114,843
Jews females
Jews males
J Relig Health
123
J Relig Health Table 4 All site cancers—number of cases in each population
Fig. 1 All site cancers agestandardized rates (ASR) of Druze versus Arabs and Jews. From top to bottom (in each group of bars): Jewish females, Arab females, Druze females, Jewish males, Arab males, Druze males
Year
Druze
Arabs
Jews
Males
Females
Males
Females
Males
Females
1999
53
40
641
512
8,742
9,760
2000
49
48
656
553
9,003
9,811
2001
91
59
743
611
9,473
10,197
2002
67
70
706
668
9,411
10,105
2003
74
65
795
655
9,885
10,266
2004
77
70
789
694
10,128
9,990
2005
103
83
937
808
10,250
10,582
2006
94
76
949
819
10,753
10,777
2007
95
87
950
987
11,139
11,005
2008
82
113
1,007
909
10,800
11,183
2009
114
99
1,064
1,029
10,600
11,167
200.0
300.0
2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 0.00
123
100.0
400.0
J Relig Health Fig. 2 Prostate cancer agestandardized rates (ASR) of Druze versus Arabs and Jews. From top to bottom (in each bars group): Jews, Arab, Druze
2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999
Fig. 3 Cervix in situ agestandardized rates (ASR) of Druze versus Arabs and Jews. From top to bottom (in each group of bars): Jews, Arab, Druze
0
20
40
60
80
100
0
5
10
15
20
25
2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999
123
J Relig Health
All Site Cancers Males Arab/Druze 5 4 3 2 1 0
09
08
20
07
20
06
20
05
20
04
20
03
20
20
20
01
00
09
08
20
07
20
06
20
05
20
04
20
20
03
02
20
01
20
20
20
19
All Site Cancers Females Jews/Druze 5 4 3 2 1 0
09
08
20
07
20
06
20
05
20
20
04 20
03
02
20
01
20
20
20
19
00
R2 = 0.8032
All Site Cancers Females Arab/Druze 5 4 3 2 1 0
02 20 03 20 04 20 05 20 06 20 07 20 08 20 09
01
20
20
20
19
00
R2 = 0.3918
99
Fig. 7 Time trends of cancer rates, Arab versus Druze, Females
00
R2 = 0.2681
99
Fig. 6 Time trends of cancer rates, Jews vs. Druze, Females
20
20
19
All Site Cancers Males Jews/Druze 5 4 3 2 1 0
99
Fig. 5 Time trends of cancer rates, Jews vs. Druze, Males
02
R2 = 0.1561
99
Fig. 4 Time trends of cancer rates, Arab vs. Druze, Males
Comparison of Cancer Rates of Males Versus Females in the Druze Population (Table 2) Cancer rates among Druze were higher in males versus females (RR = 1.21, 95 % CI = 0.99–1.47). The main differences occurred in lung cancer (RR = 5.48, 95 % CI = 2.02–14.92) and bladder cancer (RR = 7.20, 95 % CI = 2.02–25.68). For cancer of the larynx, an increased risk was not found at the 95 % CI level, but at the 90 % CI level, it occurred more often among males (RR = 15.9, 90 % CI = 1.44–176.4).
123
J Relig Health
Time Trends Time trends are described in Figs. 4, 5, 6 and 7. The difference between the Arab and Jews cancer rates compared to the Druze cancer rates is becoming smaller with the years. However, the opposite trend was observed for females with Non-Hodgkin’s lymphoma for both Arab/Druze and Jews/Druze groups, thyroid females for Jews/Druze and kidney cancer males for Arab/Druze. For invasive breast cancer, all the results were statistically significant for Jews/Druze.
Discussion Studying cancer rates in close population groups have both informational and practical importance. Cancer incidence and death rates vary considerably among ethnic groups (Siegel et al. 2013). Higher breast cancer incidence rates were found among whites compared to women of other racial or ethnic groups (Siegel et al. 2013). This can reflect a combination of more prevalent diagnosis (mammography) among white woman and disease risk factors such as later age at first pregnancy and greater use of menopausal hormone therapy among white women (Siegel et al. 2013). Opportunities to reduce cancer disparities exist in prevention, early detection, treatment, and palliative care (Ward et al. 2004). One study on the relationships between risk factors and breast cancer risk in three ethnic groups in New Zealand found differences in exposures and patterns of risk factors for breast cancer between ethnicities. The authors concluded that reducing the burden of breast cancer in New Zealand is likely to require different approaches for different ethnic groups (Jeffreys et al. 2013). To the best of our knowledge, this paper is the first report on cancer incidence rates among the Druze compared to other ethnic groups in Israel. The Druze had lower cancer rates compared to both Arabs and Jews, for both males and females. Cancer rates among males were higher than among females in all three ethnic groups, but this gender difference was not statistically significant among Jews. The higher cancer rates among males are mostly for smoking-related cancers (lung, bladder and larynx). One study conducted in Israel found that exposure to second-hand smoke (SHS) was lower in Christian Arabs (OR = 0.50, 95 % CI 0.36–0.69; p \ 0.0001), Muslim Arabs (OR = 0.56, 95 % CI = 0.42–0.74; p \ 0.0001) and Druze (OR = 0.33; 95 % CI = 0.22–0.49; p \ 0.0001) compared to Jews (reference group). The more religious persons were less exposed than secular respondents (reference group) among the Druze (OR = 0.62, 95 % CI = 0.49–0.80; p \ 0.001; Ben Noach et al. 2012). Smoking is known to be associated with lower socioeconomic status, which is often reflected in the level of education attained. (Laaksonen et al. 2005; Hiscock et al. 2012). In the Israel National Health Interview Survey (INHIS-1) carried out by the Israel Center of Disease Control (ICDC) 2003–2004, as a part of EUROHIS 2003–2004, it was found that among Arab and Jewish males, there was an inverse relationship between smoking and education level. Significantly lower smoking rates were seen among those with post-high school education. Among Arabs, there were similar smoking rates between those with less than 12 years of education and high school (46.2 and 48.6 %, respectively). For those with post-high school education, the rate was lower -39.3 %. For Jews, the smoking rates among those with a high school education was a little lower (31.8 %) than the rate among those with less than 12 years of education (34 %). Among those with post-high school education,
123
J Relig Health
the rate was reduced to 20 %. In all education levels, smoking rates were higher among the Arabs compared to Jews, a gap which is especially notable among those with college education. (INHIS-1 2003). Time trends show that the Druze cancer rates are getting closer toward the Arab and Jews populations with time, probably because of nutrition, lifestyle and environmental factors. The opposite trend was observed for females Non-Hodgkin’s lymphoma, female thyroid for Jews/Druze, and kidney cancer males for Arab/Druze. The reasons for this are not known. Effect of Consanguinity Inter-familial marriage can be a possible explanation for higher cancer rates among Arabs. Freundlich and Hino (1984) examined the rates of marriage within the family among the Arab population in the Western Galilee region in Israel and found the highest rates among the Druze (49 %) and second among Muslims (40 %). The lowest rate was found among Christians (29 %) (Freundlich and Hino 1984). Jaber et al. (1996) found that 44 % of the inter-familial marriages among the Arab population were among family relatives—half among first degree cousins, 45 % among Muslims and 32 % among Christians. Socioeconomic differences and the will to preserve family status explained a large part of interfamilial marriage rates, which were much higher among the rural versus urban Arab populations (Jaber et al. 1996). Vardi-Salitnik et al. (2002) examined consanguineous marriages in Israeli Arabs and Druze. They found high consanguinity rates in Muslim Arabs (42 %), Christian Arabs (22 %) and Druze (47 %). The rate of first cousin mating was predominantly associated with the level of education (Vardi-Salitnik et al. 2002). The Druze consider the problem of marriages to non-Druze especially severe among Druze families who live in Western countries far from home. Usually, the sons and daughters marry with locals and then the family becomes non-Druze. In some cases, these families decide to return to live in the original country in order to solve the non-consanguineous marriage problem (Halabi 2002). Thus, the Druze have lower cancer rates even though marriage within the family is more prevalent among Arabs. Indeed, an association between marriage in the community and high prevalence of malformation within the Arab population was studied in the last decade. The rate of malformations within children whose parents are family relatives is 2.5-fold higher than the rate among children of unrelated parents (Ministry of Health, Center of Disease Control report 2004, 2008). The trend of the inter-familial marriage among Arabs in Israel has decreased between 1961 and 1985, from 50.6 % among married couples in 1961–1965 to 40.6 % in 1981–1985. According to the follow-up of four townships (Taibe, Tira, Kalanswa, and Bara), consanguinity was reduced from 52.9 % in 1961–1970 to 32.8 % in 1991–1998 (Jaber et al. 1992). Effect of Occupation Male workers have been found to be two to four times more likely to report exposure to risk factors (dust, chemicals, noise, irregular hours, night shifts and vibrating tools) than women (Eng et al. 2011). A positive and significant relationship was found between the proportion of males in the workplace and the all-cause mortality risk for males. A 1 % increase in the proportion of males in the workplace was associated with a 1.3 % higher mortality risk. However, the proportion of males in the workplace is not significantly
123
J Relig Health
associated with all-cause mortality risk for females. Since males are more likely to engage in consumption patterns detrimental to health than females, they are also more exposed to lifestyle risks (alcohol, unhealthy nutrition) due to their higher proportion in the workplace (Barclay 2013; Kraft et al. 1993). Since the Druze population is currently more involved in industrial occupations than in the past, it is more likely for Druze men to be exposed to carcinogenic occupational and environmental risk factors. This may explain the higher rate of cancer in men compared to women in all three ethnic groups of our study. Study Limitations The main limitations of this study are the use of age-standardized rates, based on the world population as a standard. We do not have the crude data that describe the population better. The study lacks information about potential confounding, for example, specific exposures of the studied populations such as smoking, occupational exposure, education level and lifestyle. For example, one study found there are major differences in dietary patterns among Jews and Arabs, and a high proportion of participants adhered to ethnic dietary traditions. Participants in the top ethnic intake tertile (97 % Arab) had modified Mediterranean style Arabic dietary habits, whereas those in the bottom ethnic tertile (98 % Jewish) had central/northern European style dietary habits. Diminished ethnic differences in dietary patterns were found between Arabs and Jews among mixed population, for example, younger and males Arab who worked or studied in Jewish towns, or Jews who were born in or had a longer period of residence in Israel. The proportion of Jews who adhered to a Western-style healthy dietary pattern was higher than that of Arabs (Abu-Saad et al. 2012). Unfortunately, specific data on the Druze nutrition versus Arab are lacking. The findings of this study seek to draw attention to the lower cancer rates among the Druze population in comparison with Arabs and Jews. The Druze have lower cancer rates even though marriage within the family is more prevalent among Arabs. This new information can foster more studies into the reasons for the cancer incidence differences between the different population groups. The lower cancer rates may be related to specific genetics or to lifestyle patterns, occupational and environmental exposures of Druze versus Arabs and Jews populations. Conclusion Druze were found to have lower cancer rates compared to both Arabs and Jews, in both genders. Cancer rates among males were found to be higher than among females. Higher cancer rates among Druze were observed for smoking-related cancers. Thus, special preventative and educational efforts should be directed to Druze in all ages.
References Abu-Saad, K., Murad, H., Lubin, F., Freedman, L. S., Ziv, A., Alpert, G., et al. (2012). Jews and Arabs in the same region in Israel exhibit major differences in dietary patterns. Journal of Nutrition, 142(12), 2175–2181. Adami, H. O., Hunter, D., & Trichopoulos, D. (2002). Textbook of cancer epidemiology. New York: Oxford University Press. Barclay, K. J. (2013). Sex composition of the workplace and mortality risk. Journal of biosocial science, 45(6), 807–821.
123
J Relig Health Ben Noach, M., Steinberg, D. M., Rier, D. A., Goldsmith, R., Shimony, T., & Rosen, L. J. (2012). Ethnic differences in patterns of secondhand smoke exposure among adolescents in Israel. Nicotine & Tobacco Research, 14(6), 648–656. Eng, A., Mannetje, A., Mclean, D., Ellison-Loschmann, L., Cheng, S., & Pearce, N. (2011). Gender difference in occupational exposure patterns. Occupational and Environmental Medicine, 68, 888–894. Fisher, Y., Shetrit, A., Barchana, M., Modan, B. (2003). Assessment of the completeness of the Israel cancer registry database—methods and findings [in Hebrew]. Israel Center for Disease Control. www.health. gov.il. Freundlich, E., & Hino, N. (1984). Consanguineous marriage among rural Arabs. Israel Journal of Medical Sciences, 20, 1035–1038. Goldberger, N., Aburbeh, M., Haklai, Z. (2010). Leading causes of death in Israel 2000–2010, Ministry of Health http://www.health.gov.il/PublicationsFiles/leading_causes_2010.pdf. Halabi, M. (2002). The Druze Community. Israel: Asia publication. Hiscock, R., Bauld, L., Amos, A., Fidler, J. A., & Marcus, M. (2012). Socioeconomic status and smoking: A review. Annals of the New York Academy of Sciences, 1248, 107–123. INHIS-1 2003–2004. (2003). ICDC National Health Survey in Israel. Ministry of Health publication number 249, October 2006. Part of EUROHIS—European Health interview Surveys (an international survey that was developed by the World Health Organization). http://www.old.health.gov.il/Download/pages/ INHIS_2003-2004.pdf. Israel National Cancer Registry. http://www.health.gov.il/UnitsOffice/HD/ICDC/ICR/CancerIncidence/ Pages/about.aspx. Israeli Statistics Bureau. http://www.cbs.gov.il/www/hodaot2012n/11_12_102b.doc. Jaber, L., Merlob, P., & Bu, X. (1992). Marked parental consanguinity as a cause for increased major malformations in an Israeli Arab community. American Journal of Medical Genetics, 44, 1–6. Jaber, L., Shohat, M., & Halpern, G. J. (1996). Demographic characteristics of the Israeli Arab community in connection with consanguinity. Israel Journal of Medical Sciences, 32, 1286–1289. Jeffreys, M., McKenzie, F., Firestone, R., Gray, M., Soo, M. A., Pearce, N., et al. (2013). A multi-ethnic breast cancer case–control study in New Zealand: Evidence of differential risk patterns. Cancer Causes and Control, 24(1), 135–152. Kraft, J. M., Blum, T. C., Martin, J. K., & Roman, P. M. (1993). Drinking patterns and the gender mix of occupations: Evidence from a national survey of American workers. Journal of Substance Abuse, 5, 157–174. Laaksonen, M., Rahkonen, O., Karvonen, S., & Lahelma, E. (2005). Socioeconomic status and smoking. Analysing inequalities with multiple indicators. European Journal of Public Health, 15(3), 262–269. Ministry of Health, Center of Disease Control report. (2004). The Health condition of the Arab population in Israel 2004. Publication 226, July 2005. http://www.old.health.gov.il/Download/pages/arab2004_ 291109.pdf. Ministry of Health, Center of Disease Control report. (2008). The Health condition of the Arab population in Israel 2008. Publication 329, November 2010. http://www.old.health.gov.il/download/pages/arab2008. pdf. Ministry of Industry Commerce and Occupation. (2005). Population of Druze in Israel, 2003, characteristics of work force, occupation and unemployment. In: Ronit Nadiv, Ronit Haris-Olshek & Meirav Greenshtein (Eds.), June 2005. http://www.moital.gov.il/NR/rdonlyres/A803D5EB-2109-4E66-B8E92A3CFD84A897/0/X6565.pdf. Nisan, M. (2010). The Druze in Israel: Questions of identity, citizenship, and patriotism. The Middle East Journal, 64(4), 575–596. Siegel, R., Naishadham, D., & Jemal, A. (2013). Cancer statistics, 2013. CA: A Cancer Journal for Clinicians, 63, 11–30. Vardi-Salitnik, R., Friedlander, Y., & Cohen, T. (2002). Consanguinity in a population sample of Israeli Muslim Arabs, Christian Arabs and Druze. Annals of Human Biology, 29(4), 422–431. Ward, E., Jemal, A., Cokkinides, V., Singh, G. K., Cardinez, C., Ghafoor, A., et al. (2004). Cancer disparities by race/ethnicity and socioeconomic status. CA: A Cancer Journal for Clinicians, 54(2), 78–93.
123
