all persons living in 2 sami municipalities in northernmost finland ( inari and utsjoki ) on 31 december 1978 were identified from the finnish population information system .
the sami were identified by using the material of the finnish international biological program , human adaptability section .
those data were produced by interviewing the sami themselves and by genealogical sources ( 1 , 11 ) . in the current study ,
a person representing at least 75% of any ethnic subgroup of sami was classified as a sami .
because of historical computational reasons , the non - sami were restricted to those born between the 1st and 24th day of any month of any year . the final cohort consisted of 2,091 sami and 4,161 non - sami people .
all persons in this cohort had personal identity codes given to all residents who have lived in finland in 1967 or later and used in all person registers in finland .
the cohort was updated from statistics finland with information on dates and causes of death up to 31 december 2009 .
the cohort was also linked with the finnish cancer registry including incident cancer cases diagnosed during 19792009 .
the outcome is a net survival measure representing survival from a specified cause of death , in this case the patients cancer , in the absence of other causes of death .
the survival times of individuals who died from causes other than those specified are considered to be censored .
the cancer - specific survival experience of patients classified as sami and non - sami was compared with that of the finns outside the cohort .
the 5-year cancer - specific survival was estimated only for all cancers combined because of the small numbers of individual cancers . to produce comparative cancer - specific survival figures ,
the sami cancer patients were matched to other finnish cancer patients obtained from the finnish cancer registry with respect to site , gender , age at diagnosis and year of diagnosis , and in a separate analysis also with respect to the stage .
the stage was analyzed in five categories : ( a ) localized , ( b ) regional , ( c ) distant , ( d ) non - localized , not known whether regional or distant , and ( e ) unknown .
cancer - specific analyses were conducted using the matched cox regression model ( 12 ) .
weighted survival analyses were made separately for sami and non - sami cancer patients using the kaplan - meier method .
the weight for each matched control was calculated as the inverse of the number of controls for each case ( i.e. weight=1/number of controls for each case ) .
the statistical software stata was used to calculate 5-year cumulative weighted cause - specific survival figures .
in addition to the cancer - specific analyses , regular matched overall or all - cause survival analyses were also performed , disregarding the cause of death information .
all persons living in 2 sami municipalities in northernmost finland ( inari and utsjoki ) on 31 december 1978 were identified from the finnish population information system .
the sami were identified by using the material of the finnish international biological program , human adaptability section .
those data were produced by interviewing the sami themselves and by genealogical sources ( 1 , 11 ) . in the current study ,
a person representing at least 75% of any ethnic subgroup of sami was classified as a sami .
because of historical computational reasons , the non - sami were restricted to those born between the 1st and 24th day of any month of any year . the final cohort consisted of 2,091 sami and 4,161 non - sami people .
all persons in this cohort had personal identity codes given to all residents who have lived in finland in 1967 or later and used in all person registers in finland .
the cohort was updated from statistics finland with information on dates and causes of death up to 31 december 2009 .
the cohort was also linked with the finnish cancer registry including incident cancer cases diagnosed during 19792009 .
the outcome is a net survival measure representing survival from a specified cause of death , in this case the patients cancer , in the absence of other causes of death .
the survival times of individuals who died from causes other than those specified are considered to be censored .
the cancer - specific survival experience of patients classified as sami and non - sami was compared with that of the finns outside the cohort .
the 5-year cancer - specific survival was estimated only for all cancers combined because of the small numbers of individual cancers . to produce comparative cancer - specific survival figures ,
the sami cancer patients were matched to other finnish cancer patients obtained from the finnish cancer registry with respect to site , gender , age at diagnosis and year of diagnosis , and in a separate analysis also with respect to the stage .
the stage was analyzed in five categories : ( a ) localized , ( b ) regional , ( c ) distant , ( d ) non - localized , not known whether regional or distant , and ( e ) unknown .
cancer - specific analyses were conducted using the matched cox regression model ( 12 ) .
weighted survival analyses were made separately for sami and non - sami cancer patients using the kaplan - meier method .
the weight for each matched control was calculated as the inverse of the number of controls for each case ( i.e. weight=1/number of controls for each case ) .
the statistical software stata was used to calculate 5-year cumulative weighted cause - specific survival figures .
in addition to the cancer - specific analyses , regular matched overall or all - cause survival analyses were also performed , disregarding the cause of death information .
there were 204 cancer cases in the sami cohort , 391 in the non - sami cohort .
the number of controls was 20,181 when cancer patients were matched with respect to site , gender , age at diagnosis and year of diagnosis and 7,874 when also matched with respect to stage .
survival until 5 years after diagnosis was first compared without considering the stage and later also matching for stage . in the cancer - specific analysis without stage variable ,
the hazard ratio for sami was 1.05 ( 95% ci 0.851.30 ) and for non - sami 1.02 ( 0.861.20 ) .
when the sami cancer patients were also matched according to the stage of the cancer , the cancer - specific analyses gave a hazard ratio for the sami 1.02 ( 0.781.33 ) and for the non - sami 1.10 ( 0.911.33 ) .
the hazard ratios in the all - cause observed 5-year survival analysis were 1.13 ( 0.941.37 ) for the sami and 0.97 ( 0.841.12 ) for the non - sami . in the survival curves ( fig .
1 ) a small difference can be seen between survival of the sami and matched controls .
the curves of sami and non - sami and their matched controls run at different levels in the figures .
cumulative cancer - specific survival curves of all cancer sites combined for the sami and non - sami cancer patients in inari and utsjoki compared with controls of finnish population , matched with respect to site , gender , age at diagnosis and year of diagnosis .
only the survival of all sites of cancer could be assessed because of the low number of cancer cases . because the different sami groups could only be assessed together due to the small numbers of cancer cases in each of them , the possible survival differences between the sami categories could not be assessed .
the starting assumption of this study was that both genetic or lifestyle features of the sami , and long distances to the medical care and to hospitals could have an influence on the survival of cancer .
the results , however , do not support these hypotheses . about half of the sami people in this cohort were born before 1950 , and hence have been living according to the traditional sami culture .
the quality of food was healthy , including reindeer meat , fish and berries . before the era of cars and other motor vehicles , the sami had to do a lot of exercise .
the increased communication between the sami area and other districts brought along more smoking , alcohol drinking , and unhealthy eating habits , but also a higher living standard , better health care and facilities , making life easier .
finnish legislation since 1969 has made it possible to get a 75% subsidy for the costs for building new reindeer farms , and in that way affecting the well - being and health of reindeer herders .
the skolt sami have their own legislation , which helps their living conditions . from the 1970s ,
the ways of life of the sami and the non - sami have been very much alike , also with regard to how they seek health services .
a publication from the usa describes and compares cancer - specific survival ratios of patients of 6 major racial or ethnic groups during the years 19751997 in the usa ( 13 ) . in 19751987 ,
the cancer survival ratio of american indian and alaskan native patients was the lowest ; 25% in males and 36% in females ( 13 ) .
although the 5-year survival ratios of cancer patients during 19881997 in any group were more favourable than in 19751987 , the differences between ethnic groups persisted .
an 11 percent - unit lower all - site cancer survival ratio was reported in a comparison between the alaska natives and the usa caucasian cancer patients in 19841994 ( 14 ) .
however , the mortality / incidence ratios in the northernmost finland in the 1950s suggest that the survival of cancer patients in that area was worse than in the rest of finland , but the difference disappeared before the 1970s , thanks to a more rapid decrease in the mortality / incidence ratio in the north ( 15 ) . it is likely that the survival of patients with cancer ( and other diseases ) improves when the living standard increases and the living conditions get better .
one has to remember that the living circumstances such as distances , living standards , and social situations of indians and alaskan natives are quite different from those of the sami in finland .
the explanation for the similar cancer survival of sami and non - sami and the finnish population might be the similar possibilities to get physician consultations and care everywhere in finland .
when the sickness insurance act came into force 1964 , it recognized the need for travelling to the medical doctor . from that time on it was possible to get reimbursement for travelling costs . for those who lived far from services ( health centre , shops , banks etc . ) , it was practical to also manage other things such as shopping when coming to visit the doctor . hence , the threshold to visit the doctor was rather low , similarly for the sami and non - sami from the northernmost finland . in the past
, language has been a problem , because all the 3 sami groups in finnish lapland speak different sami languages , and it is clear that physicians and public health nurses , who came from the south did not speak sami at all , and sami nurses spoke only their own sami language .
the utsjoki municipality later got northern - sami speaking general practitioners ( gp ) and nurses . today
health care workers receive a salary increment if they speak a sami language . when the public health act came into force in 1972 , it was a big step towards better health care , especially in the sparsely populated rural areas .
new health centres , often with beds , were built , more posts for medical doctors and other staff were established , and especially , the health education and early detection of diseases was prioritized .
the equality in health care should have been realized , providing the same system and same rules for everybody . in the inari health centre during the time of this study , there were 6 gp posts and 35 beds .
a local deviation or application from the public health act was that the doctors met patients not only in health centres but also in remote sami villages .
when travelling to the remote villages , the gp also made home visits on the way . in the inari municipality and partly also in utsjoki , there were the same gps working from the beginning of the 1970s until they gradually retired from 2005 .
these gps knew well the population and circumstances , which benefits the early diagnosing of diseases , also cancer .
the sami and non - sami in utsjoki and inari had all possibilities for early detection , which is an important reason for better survival .
from the present study we see that there was no difference between the results with and without adjustment for the stage .
when the nearest central hospital in rovaniemi got its own oncologist in the beginning of 1990s , most cancer patients no longer needed to travel to oulu ( another 200 km further ) , unless a specialized treatment such as radiotherapy was required . because of the experienced gps and good cooperation with the central hospital oncologist , it was possible to follow the treatment plan in the local health centre and carry out such cancer treatments ( e.g. chemotherapy ) , which normally are implemented in central hospitals .
special investigations such as tomography , mri and ultrasound were done in the central hospital .
the survival curves of the sami cancer patients and their control cancer patients  matched according to sex , age and cancer type  were on a lower level than the respective curves for the non - sami and their controls ( fig .
1 ) . the reason for this difference is the different cancer type distribution of the sami and non - sami .
the sami have a lower incidence of cancers with high survival ( cancers of the skin , breast , prostate , testis , kidney , bladder and thyroid , and hodgkin lymphoma ) than the non - sami , while the incidence of more lethal common cancer types such as stomach cancer or lung cancer is not lower ( 4 ) .
the sami persons were also older than the non - sami , and older cancer patients tend to have lower relative survival rates than young ones .
there was no difference between the all - cause survival of sami and non - sami and other patients in finland .
the higher mortality hazard in the sami patients may well also reflect a higher mortality from the other causes of death ( 10 ) , which may as well be partly due to the higher age of the sami compared to the non - sami . during the study period ( 19792009 )
, the survival of cancer patients in the far north has been the same as in finland generally . that concerns both sami and non - sami patients , which means that neither long distances in finland nor ethnic background have an effect on surviving .
these results might also tell something about good and persistent patient - physician relationships ( early detection ) , which are known to advance the surviving of all diseases .
the authors have not received any funding or benefits from industry or elsewhere to conduct this study .
 objectivesthe incidence of cancer among the indigenous sami people of northern finland is lower than among the finnish general population . 
 the survival of sami cancer patients is not known , and therefore it is the object of this study.study designthe cohort consisted of 2,091 sami and 4,161 non - sami who lived on 31 december 1978 in the two sami municipalities of inari and utsjoki , which are located in northern finland and are 300500 km away from the nearest central hospital . the survival experience of sami and non - sami cancer patients diagnosed in this cohort during 19792009 was compared with that of the finnish patients outside the cohort.methodsthe sami and non - sami cancer patients were matched to other finnish cancer patients for gender , age and year of diagnosis and for the site of cancer . 
 an additional matching was done for the stage at diagnosis . 
 cancer - specific survival analyses were made using the kaplan  meier method and cox regression modelling.resultsthere were 204 sami and 391 non - sami cancer cases in the cohort , 20,181 matched controls without matching with stage , and 7,874 stage - matched controls . in the cancer - specific analysis without stage variable , 
 the hazard ratio for sami was 1.05 ( 95% confidence interval 0.851.30 ) and for non - sami 1.02 ( 0.861.20 ) , indicating no difference between the survival of those groups and other patients in finland . 
 likewise , when the same was done by also matching the stage , there was no difference in cancer survival.conclusionlong distances to medical care or sami ethnicity have no influence on the cancer patient survival in northern finland . 
Material and methods
The cohort
Statistical analyses
Results
Discussion
Conflict of interest and funding