In this population-based cohort of patients in California with lung or colorectal cancer, we observed lower patient ratings of cancer care among foreign-born patients relative to U.S.-born patients as well as among Hispanic and Asian individuals. These differences were partially explained by English language proficiency. We also observed lower rates of adjuvant chemotherapy and radiation therapy for stage II/III rectal cancer among foreign-born patients compared with US-born patients. We did not observe differences in rates of adjuvant chemotherapy for stage III colon cancer or curative surgery for stage I/II lung cancer. However, moderate-sized differences may have been missed due to relatively small sample sizes in these groups.
The Institute of Medicine has emphasized the importance of patient-centered care, declaring patient-centeredness to be one of six key aims of high-performing health care organizations(32
). Previous research has found that racial or ethnic minorities with cancer and other conditions rate their care less favorably than white patients(33
); this difference is particularly pronounced among non-English speaking patients(33
). Asian and Hispanic patients have more problems than whites with coordination of care, access to care, and access to health and treatment information(35
). The complexity of cancer care and the need for timely information about the disease and treatment options, which often require substantial coordination of care among multiple specialists, may be particularly challenging for foreign-born patients if they have limited social support to help with navigating the health care system. These challenges can be compounded by communication difficulties between non-English speaking patients and their clinicians, particularly if trained interpreters are unavailable and the clinicians do not speak the patients’ language.
Our finding of lower rates of adjuvant chemotherapy and radiation therapy for stage II/III rectal cancer among foreign-born patients is particularly notable because receipt of adjuvant therapies for rectal cancer typically requires coordination of multi-modality therapy by different providers, and sometimes requires neoadjuvant treatment. The lower rates of effective adjuvant therapy for rectal cancer by nativity is consistent with the findings of lower rates of guideline-recommended treatment for breast cancer among foreign-born Hispanic(1
) and Asian(36
) patients. Another small study also demonstrated less combined modality therapy for foreign-born Asian patients with lung cancer compared with non-Asian patients(38
). The lack of differences by nativity in receipt of other treatments we studied may be because single modality therapy is less complex. One study found higher rates of complete surgical treatment of gastric cancer among foreign-born Asian and Pacific Islander patients than non-Hispanic white patients(13
Issues of language and acculturation are important considerations in understanding differences in patients’ experiences with care. For newly diagnosed cancer patients who face a series of complex decisions regarding treatment, including trade-off between chances of cure, side effects and quality of life, good communication between the patient and the health care providers is crucial. Limited English proficiency may hamper communication as well as coordination and access to recommended care(33
). Trained medical interpreters as well as patient navigator programs can improve care for patients with limited English proficiency(40
), yet trained interpreters are available in person or by phone less than half of the times they are needed for patients with cancer, particularly in solo practices and single-specialty medical groups(41
), and navigator programs are even less commonly available.
Language explained some of the lower ratings of care observed for Hispanic versus white patients, but not that for Asian versus white patients. Additional research is needed to understand what care beyond interpreter services is needed to improve experiences with care, particularly for Asian patients. While the observed findings point to language barriers as a prominent reason for disparities, the degree of adherence to native cultural beliefs and norms may also play a strong role, particularly in decisions about treatment options. In a prior study of providers who treat Asian patients with breast cancer, fear and cultural beliefs were among the most common reasons these patients chose mastectomy over breast-conserving surgery(42
). Further research is needed to understand the role of acculturation, language, and cultural factors in treatment decision-making among foreign-born patients with cancer. Few patients in our study were recent immigrants, limiting our ability to assess the influence of years in the U.S. on treatment decisions.
Strengths of our study included a large population of foreign-born patients of different racial and ethnic groups surveyed in one of 3 languages and with survey data supplemented by registry and medical record data. In addition, we assessed patients’ ratings of quality of care as well as receipt of cancer treatment among patients with lung and colorectal cancer who were US-born and foreign-born.
Several limitations of our study should also be noted. First, despite the relatively large numbers of patients, we had limited power to detect differences of moderate size for some measures that still may be clinically important, as evidenced by the relatively wide confidence intervals for some treatments. For example, we had >80% power to detect an absolute difference of 12% in adjuvant chemotherapy for stage III colon cancer between US-born and foreign-born patients, and an absolute difference of 15% for curative surgery for stage I/II lung cancer between these groups. We had less statistical power to detect potential interactions of nativity by race/ethnicity. Thus, studies with larger sample sizes may be needed to detect smaller differences in receipt of recommended care by nativity. Second, patient-reported quality of care measured by a single item might be conceptually or psychometrically problematic if individuals in different race/ethnic groups or with different levels of acculturation do not ascribe the same meaning to the response categories. Some evidence from the Consumer Assessments of Healthcare Providers and Systems (CAHPS) survey suggest that Hispanic and Asian individuals report care experiences that are similar to or less positive than care for non-Hispanic whites, yet they have more positive ratings of care(43
), and Hispanic patients are more likely to use the extremes of response scales(44
). Our results were robust to alternative definitions of high-quality care, suggesting that differences in reporting the highest levels of quality are unlikely to explain our results; nevertheless, additional validation of single-item quality assessments in varied racial/ethnic groups is needed.
Third, we have no information about how non-respondent foreign-born patients may differ from respondents. Fourth, we studied patients in California, limiting the generalizability of the findings to immigrants in other parts of the US, where the characteristics of immigrant populations may differ (45
). Moreover, we were unable to assess specific racial/ethnic subgroups that may differ in their culture, religion, beliefs, and practices concerning health; this may especially be true for Asians who constitute a heterogeneous group; however, nearly half of the Asians in our sample were of Chinese origin. Finally, foreign-born patients were less likely than others to consent to medical record abstraction. Nevertheless, we supplemented information from the medical records with self-reports of chemotherapy and radiation, which prior studies demonstrate are quite accurate (26
). Since the analyses for lung cancer surgery required medical record data, foreign-born patients who did not consent to medical record abstraction were not included in this analysis.
In conclusion, foreign-born individuals with lung or colorectal cancer reported lower quality of care than US-born patients and were less likely to receive some complex cancer treatments that are recommended by clinical guidelines. These differences were at least partly explained by English language proficiency. Cancer experiences and outcomes may be improved with a greater emphasis on coordination of care and improving communication with foreign-born patients, including providing additional services for these patients, such as interpreters and patient navigators.