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1.  Cancer incidence and mortality patterns among specific Asian and Pacific Islander populations in the U.S. 
Cancer Causes & Control   2007;19(3):227-256.
We report cancer incidence, mortality, and stage distributions among Asians and Pacific Islanders (API) residing in the U.S. and note health disparities, using the cancer experience of the non-Hispanic white population as the referent group. New databases added to publicly available SEER*Stat software will enable public health researchers to further investigate cancer patterns among API groups.
Cancer diagnoses among API groups occurring from 1 January 1998 to 31 December 2002 were included from 14 Surveillance, Epidemiology, and End Results (SEER) Program state and regional population-based cancer registries covering 54% of the U.S. API population. Cancer deaths were included from the seven states that report death information for detailed API groups and which cover over 68% of the total U.S. API population. Using detailed racial/ethnic population data from the 2000 decennial census, we produced incidence rates centered on the census year for Asian Indians/Pakistanis, Chinese, Filipinos, Guamanians, Native Hawaiians, Japanese, Kampucheans, Koreans, Laotians, Samoans, Tongans, and Vietnamese. State vital records offices do not report API deaths separately for Kampucheans, Laotians, Pakistanis, and Tongans, so mortality rates were analyzed only for the remaining API groups.
Overall cancer incidence rates for the API groups tended be lower than overall rates for non-Hispanic whites, with the exception of Native Hawaiian women (All cancers rate = 488.5 per 100,000 vs. 448.5 for non-Hispanic white women). Among the API groups, overall cancer incidence and death rates were highest for Native Hawaiian and Samoan men and women due to high rates for cancers of the prostate, lung, and colorectum among Native Hawaiian men; cancers of the prostate, lung, liver, and stomach among Samoan men; and cancers of the breast and lung among Native Hawaiian and Samoan women. Incidence and death rates for cancers of the liver, stomach, and nasopharynx were notably high in several of the API groups and exceeded rates generally seen for non-Hispanic white men and women. Incidence rates were lowest among Asian Indian/Pakistani and Guamanian men and women and Kampuchean women. Asian Indian and Guamanian men and women also had the lowest cancer death rates. Selected API groups had less favorable distributions of stage at diagnosis for certain cancers than non-Hispanic whites.
Possible disparities in cancer incidence or mortality between specific API groups in our study and non-Hispanic whites (referent group) were identified for several cancers. Unfavorable patterns of stage at diagnosis for cancers of the colon and rectum, breast, cervix uteri, and prostate suggest a need for cancer control interventions in selected groups. The observed variation in cancer patterns among API groups indicates the importance of monitoring these groups separately, as these patterns may provide etiologic clues that could be investigated by analytic epidemiological studies.
PMCID: PMC2268721  PMID: 18066673
Cancer; Incidence; Mortality; Race; Ethnicity; Asian; Pacific Islander; SEER Program
2.  Risk of cancer-specific, cardiovascular, and all-cause mortality among Asian and Pacific Islander breast cancer survivors in the United States, 1991–2011 
SpringerPlus  2016;5:82.
Asian and Pacific Islander (API) women in the United States (U.S.) are a heterogeneous group reported to have better prognosis after breast cancer (BC) compared to their Non-Hispanic White (NHW) counterparts. Few studies have examined differences in BC survival between individual API ethnic groups. We conducted a retrospective cohort study of 462,005 NHW and 44,531 API women diagnosed with incident, stage I–III BC between 1991 and 2011 in the Surveillance, Epidemiology and End Results (SEER) 18 registries. SEER-reported API ethnicity was grouped as Chinese, Japanese, Filipino, Hawaiian, Korean, Vietnamese, Asian Indian and Pakistani, and Pacific Islander. Multivariable Cox proportional hazards models were used to estimate hazard ratios (HR) and 95 % confidence intervals (CI) for risk of BC-specific, cardiovascular and all-cause mortality comparing API to NHW women. We also estimated mortality risk comparing U.S.-born to non-U.S.-born women. Compared to NHW women, API women overall had lower BC-specific, cardiovascular and all-cause mortality. BC-specific mortality risk was lowest among Japanese women (HR 0.69, 95 % CI 0.63–0.77). Other women had similar (Filipino, HR 0.93, 0.86–1.00; Hawaiian, HR 1.01, 0.89–1.17) or greater (Pacific Islander, HR 1.44, 1.17–1.78) risk of BC-specific death. Compared to non-U.S. born API women, findings were suggestive of increased cardiovascular (HR 1.12, 1.03–1.20) and all-cause mortality (HR 1.29, 1.08–1.54) among U.S.-born API women. Mortality risk varies greatly between BC survivors from different API backgrounds. Further research is warranted to understand these disparities in BC survivorship and the social and cultural factors that possibly contribute to greater mortality among later-generation API women born in the United States.
PMCID: PMC4728166  PMID: 26844029
Breast cancer; Asian American; Pacific Islander; Cancer survivorship; Mortality
3.  Uncovering disparities in survival after non-small-cell lung cancer among Asian/Pacific Islander ethnic populations in California 
Asians may have better survival after non-small-cell lung cancer (NSCLC) than non-Asians. However, it is unknown whether survival varies among the heterogeneous U.S. Asian/Pacific Islander (API) populations. Therefore, this study aimed to quantify survival differences among APIs with NSCLC. Differences in overall and disease-specific survival were analyzed in the California Cancer Registry among 16,577 API patients diagnosed with incident NSCLC between 1988 and 2007. Adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using Cox proportional hazards regression models with separate baseline hazards by disease stage. Despite better overall and disease-specific survival among APIs compared with non-Hispanic Whites, differences were evident across API populations. Among women, Japanese (overall survival HR=1.16, 95% CI=1.06–1.27) and APIs other than those in the six largest ethnic groups (“other APIs”; HR=1.19, 95% CI=1.07–1.33) had significantly poorer overall and disease-specific survival than Chinese. By contrast, South Asian women had significantly better survival than Chinese (HR=0.79, 95% CI=0.63–0.97). Among men, Japanese (HR=1.15, 95% CI=1.07–1.24), Vietnamese (HR=1.07, 95% CI=1.00–1.16), and other APIs (HR=1.18, 95% CI=1.08–1.28) had significantly poorer overall and disease-specific survival than Chinese. Other factors independently associated with poorer survival were lower neighborhood SES, involvement with a non-university-teaching hospital, unmarried status, older age, and earlier year of diagnosis. APIs have significant ethnic differences in NSCLC survival that may be related to disparate lifestyles, biology, and especially health care access or use. To reduce the nationwide burden of lung cancer mortality, it is critical to identify and ameliorate hidden survival disparities such as those among APIs.
PMCID: PMC2764550  PMID: 19622719
non-small-cell lung cancer; survival; Asian Americans; Pacific Islanders; ethnic groups
4.  Treatment and Outcomes of Gastric Cancer Among US-Born and Foreign-Born Asians and Pacific Islanders 
Cancer  2009;115(19):4595-4605.
To investigate whether stage at diagnosis, cancer treatments and survival of Asian and Pacific Islander (API) gastric cancer patients in the US vary by birthplace.
We studied 6454 API and 10,099 non-Hispanic white (NHW) patients diagnosed with gastric cancer from the Surveillance, Epidemiology and End Results Program between 1992 and 2005. In descriptive analyses we compared stage, receipt of adequate lymph node examination (ALNE) and surgery among US-born APIs, foreign-born (FB) APIs and NHWs. Multivariable polytomous logistic and proportional hazards regression models were used to assess differences in cancer stage and survival, respectively, adjusted for clinical and demographic factors.
As a group, APIs were more likely than NHWs to present with earlier-stage diagnoses and receive surgery and ALNE (p<0.001). However, FB [aOR=0.79 (0.73–0.86)] but not US-born APIs [aOR=1.05 (0.92–1.20)] were significantly more likely to present at earlier stages than NHWs. Compared to NHW patients, FB and US-born APIs were more likely to receive surgery [aRR=1.06 (1.03–1.09) and aRR=1.09 (1.03–1.14) respectively] and ALNE [aRR=1.29 (1.19–1.41) and aRR=1.14 (1.00–1.32) respectively]. In fully adjusted models, FB [aHR= 0.86 (0.82–0.90)] but not US-born APIs [(aHR= 0.96 (0.89–1.04)] had more favorable survival than NHWs.
The earlier-stage diagnosis, more complete surgical treatment and improved survival of Asians and Pacific Islanders with gastric cancer may result from less aggressive tumors or more prompt recognition and thorough evaluation of early symptoms. Further study of these factors could improve outcomes for all patients with gastric cancer.
PMCID: PMC2953712  PMID: 19626648
gastric cancer outcomes; Asian/Pacific Islanders; birthplace; ethnicity; SEER
5.  Reproductive health differences among Latin American- and US-born young women 
Investigations of reproductive health within Lationos living in the United States suggest that sexual behaviors and contraception use practices vary by ethnicity and between foreign- and US-born adolescents. This article compares high-risk sexual behaviors and reproductive health among foreign-born Latinas, US-born Latinas, and US-born non-Latinas aged 15–24 years. We recruited 361 females from reproductive health clinics in the San Francisco Bay Area of California between 1995 and 1998; these women completed an interview that assessed sexual risk behaviors and history of pregnancy, abortion, and sexually transmitted infections. Current chlamydial and gonococcal infections were detected through biological testing. Among participants aged 15–18 years, US-born Latinas were more likely to have been pregnant (odds ratio [OR] comparing US-born Latinas and US-born non-Latinas=3.9, 95% confidence interval [CI] 1.3, 11.4), whereas among respondents aged 19–24 years, foreign-born Latinas were more likely to have been pregnant than US-born Latinas (OR=11.3, 95% CI 1.0, 130.8) and US-born non-Latinas (OR=64.2, 95%CI 9.9, 416.3). US-born Latinas were most likely to have had an abortion (OR comparing US-born Latinas and US-born non-Latinas=2.0, 95% CI 0.9, 4.7). They were also most likely to have chlamydial infection at study enrollment (8.2% prevalence compared to 2.2% and 1.0% for foreign-born Latinas and US-born non-Latinas, respectively; P=0.009). Reproductive health differences between foreign and US-born females and within the US-born population warrant further examination and highlight the need for targeted prevention.
PMCID: PMC3455870  PMID: 11796809
Abortion; Adolescence; Hispanic Americans; Immigrants; Pregnancy; Sex behavior; Sexually transmitted diseases
6.  The California Breast Cancer Survivorship Consortium (CBCSC): Prognostic factors associated with racial/ethnic differences in breast cancer survival 
Cancer causes & control : CCC  2013;24(10):1821-1836.
Racial/ethnic disparities in mortality among US breast cancer patients are well-documented. Our knowledge of the contribution of lifestyle factors to disease prognosis is based primarily on non-Latina Whites and is limited for Latina, African American and Asian American women. To address this knowledge gap, the California Breast Cancer Survivorship Consortium (CBCSC) harmonized and pooled interview information (e.g., demographics, family history of breast cancer, parity, smoking, alcohol consumption) from six California-based breast cancer studies and assembled corresponding cancer registry data (clinical characteristics, mortality), resulting in 12,210 patients (6,501 non-Latina Whites, 2,060 African Americans, 2,032 Latinas, 1,505 Asian Americans, 112 other race/ethnicity) diagnosed with primary invasive breast cancer between 1993 and 2007. In total, 3,047 deaths (1,570 breast cancer-specific) were observed with a mean (SD) follow-up of 8.3 (3.5) years. Cox-proportional hazards regression models were fit to data to estimate hazards ratios (HR) and 95% confidence intervals (CI) for overall and breast cancer-specific mortality. Compared with non-Latina Whites, the HR of breast cancer-specific mortality was 1.13 (95% CI, 0.97-1.33) for African Americans, 0.84 (95% CI, 0.70-1.00) for Latinas, and 0.60 (95% CI, 0.37-0.97) for Asian Americans after adjustment for age, tumor characteristics, and select lifestyle factors. The CBCSC represents a large and racially/ethnically diverse cohort of breast cancer patients from California. This cohort will enable analyses to jointly consider a variety of clinical, lifestyle, and contextual factors in attempting to explain the long-standing disparities in breast cancer outcomes.
PMCID: PMC4046898  PMID: 23864487
race/ethnicity; survival; tumor characteristics; lifestyle factors
7.  Disparities in Perceived Unmet Need for Supportive Services Among Patients With Lung Cancer in the Cancer Care Outcomes Research and Surveillance Consortium 
Cancer  2014;120(20):3178-3191.
The authors investigated the prevalence, determinants of, and disparities in any perceived unmet need for 8 supportive services (home nurse, support group, psychological services, social worker, physical/occupational rehabilitation, pain management, spiritual counseling, and smoking cessation) by race/ethnicity and nativity and how it is associated with perceived quality of care among US patients with lung cancer.
Data from a multiregional, multihealth system representative cohort of 4334 newly diagnosed patients were analyzed. Binomial logistic regression models adjusted for patient clustering.
Patients with any perceived unmet need (9% overall) included 7% of white–US-born (USB), 9% of white–foreign-born (FB), 13% of black-USB, 8% of Latino-USB, 24% of Latino-FB, 4% of Asian/Pacific Islander (API)-USB, 14% of API-FB, and 11% of “other” patients (P <.001). Even after controlling for demographic and socioeconomic factors, health system and health care access, and need, black-USB, Latino-FB, and Asian-FB patients were more likely to perceive an unmet need than white-USB patients by 5.1, 10.9, and 5.6 percentage points, respectively (all P<.05). Being younger, female, never married, uninsured, a current smoker, or under surrogate care or having comorbidity, anxiety/depression, or a cost/insurance barrier to getting tests/treatments were associated with any unmet need. Patients with any unmet need were more likely to rate care as less-than-“excellent” by 13 percentage points than patients with no unmet need (P<.001).
Significant disparities in unmet supportive service need by race/ethnicity and nativity highlight immigrants with lung cancer as being particularly underserved. Eliminating disparities in access to needed supportive services is essential for delivering patient-centered, equitable cancer care.
PMCID: PMC4414401  PMID: 24985538
lung cancer; patient-centered care; health care disparities; underserved populations; immigrants; supportive care
8.  The “Latina Epidemiologic Paradox” Revisited: The Role of Birthplace and Acculturation in Predicting Infant Low Birth Weight for Latinas in Los Angeles, CA 
The “Latina epidemiologic paradox” refers to the observation that despite socioeconomic disadvantages, Latina mothers in the United States (US) have a similar or lower risk for delivering an infant with low birth weight (LBW) compared to non-Latina White mothers. An analogous paradox may exist between foreign-born (FB) and US-born (USB) Latinas. Our goal was to assess differences in LBW in USB Latinas, FB Latinas, and non-Latina Whites in Los Angeles County in 2003 using birth records and survey data. Using logistic regression, we estimated associations between LBW and birthplace/ethnicity in a birth cohort and nested survey responder group and between LBW and acculturation in responders to a follow-up survey. USB Latinas and FB Latinas had a higher prevalence of LBW infants compared to Whites (odds ratio [OR] = 1.34, 95% confidence interval [CI] = (1.17, 1.53) and OR = 1.32, 95% CI = (1.18, 1.49), respectively); when we adjusted for additional maternal risk factors these point estimates were attenuated, and interval estimates were consistent with a modest positive or inverse association. Among Latinas only, LBW was more common for high-acculturated FB and USB Latinas compared to low-acculturated FB Latinas, and there was limited evidence that environmental or behavior risk factors had less impact in low-acculturated Latinas. In summary, adjusting only for demographics, Latinas in our study were more likely to have LBW infants compared to Whites, in contrast to the Latina paradox hypothesis. Furthermore, adjusting for environmental or behavioral factors attenuated the positive association, but there was little evidence that Latinas had a lower prevalence of LBW regardless of the variables included in the models. Finally, among Latinas, there was limited evidence that associations between known risk factors and LBW were modified by acculturation.
PMCID: PMC3643973  PMID: 22160842
Low birth weight; Latina; Hispanic; US-born; foreign-born; Acculturation; Two-phase analysis
9.  Trends in Breast Conserving Surgery Among Asian Americans and Pacific Islanders, 1992–2000 
Breast-conserving surgery (BCS) has been the recommended treatment for early-stage breast cancer since 1990 yet many women still do not receive this procedure.
To examine the relationship between birthplace and use of BCS in Asian-American and Pacific-Islander (AAPI) women, and to determine whether disparities between white and AAPI women persist over time.
Retrospective cohort study.
Women with newly diagnosed stage I or II breast cancer from 1992 to 2000 in the Surveillance, Epidemiology, and End Results program.
Receipt of breast -conserving surgery for initial treatment of stage I or II breast cancer.
Overall, AAPI women had lower rates of BCS than white women (47% vs 59%; P<.01). Foreign-born AAPI women had lower rates of BCS than U.S.-born AAPI and white women (43% vs 56% vs 59%; P<.01). After adjustment for age, marital status, tumor registry, year of diagnosis, stage at diagnosis, tumor size, histology, grade, and hormone receptor status, foreign-born AAPI women (adjusted OR [aOR], 0.49; 95% CI, 0.32 to 0.76) and U.S.-born AAPI women (aOR, 0.77; 95% CI, 0.62 to 0.95) had lower odds of receiving BCS than white women. Use of BCS increased over time for each racial/ethnic group; however, foreign-born AAPI women had persistently lower rates of BCS than non-Hispanic white women.
AAPI women, especially those who are foreign born, are less likely to receive BCS than non-Hispanic white women. Of particular concern, differences in BCS use among foreign-born and U.S.-born AAPI women and non-Hispanic white women have persisted over time. These differences may reflect inequities in the treatment of early-stage breast cancer for AAPI women, particularly those born abroad.
PMCID: PMC1490151  PMID: 16050854
breast neoplasms; cancer treatment; health disparities; race/ethnicity; immigrant health
10.  Cigarette smoking associated with lung adenocarcinoma in situ in a large case-control study (SFBALCS) 
Adenocarcinoma in situ (AIS, formerly bronchioloalveolar carcinoma [BAC]) is an uncommon subtype of lung adenocarcinoma and accounts for approximately 3–4% of lung cancers. Compared with other lung cancer histologies, AIS cases are less likely to be smokers, yet associations with other lung cancer risk factors and differences by gender have not been determined.
A total of 338 AIS (formerly BAC) cases and frequency matched controls from the parent study (cases=6039, controls=2073) were included in these analyses. Odds ratios and 95% confidence intervals as estimates of the relative risk were obtained from multivariable unconditional logistic regression analyses.
Risk of AIS was associated with ever smoking (OR=2.7, 95% CI: 2.1, 3.6), increased 20–30% for each 10-year increase in pack-years of smoking and decreased with increased years since quitting (P for trend <0.0001). There was no evidence that risk differed by gender but there was some suggestion that risk may differ by asbestos and by second-hand tobacco smoke exposure in whites.
There is an association between AIS and smoking that is smaller in magnitude than other subtypes of non-small cell lung cancer. Our findings suggesting that effects may differ by asbestos and second-hand tobacco smoke exposure should be interpreted conservatively and warrant validation and further evaluation in larger studies of AIS.
PMCID: PMC3421052  PMID: 22814813
Adenocarcinoma in situ; case-control; epidemiology; smoking; second-hand tobacco smoke
11.  Smoking prevalence and correlates among Chinese- and Filipino-American adults: Findings from the 2001 California Health Interview Survey 
Preventive medicine  2005;41(2):693-699.
We report prevalence rates and correlates of cigarette smoking among a population-based sample of Chinese- and Filipino-American adults together with rates found in other racial/ethnic groups in California.
All analyses are based on the 2001 California Health Interview Survey.
The proportion of current smokers among males was lowest among Chinese Americans (14%), followed by Non-Hispanic Whites (19%), Hispanics (20%), African Americans (22%), Filipino Americans (24%), American Indians/Alaska Natives (29%), and Pacific Islanders (32%). The proportion of current smokers among females was lowest among Chinese Americans (6%), followed by Hispanics (8%), Filipino Americans (11%), Non-Hispanic Whites (17%), African Americans (20%), Pacific Islander (21%), and American Indians/Alaska Natives (32%). Smoking rates were higher among foreign-born versus U.S.-born Asian males. CHIS data show an opposite effect among Asian women: acculturation to the U.S. is associated with increased smoking prevalence rates. Multivariate analyses with Chinese and Filipino respondents showed that the likelihood of smoking varied among foreign-born versus U.S.-born men (OR 2.59 for Chinese, 1.42 for Filipino, 2.01 for all Asian men combined) and for foreign-born versus U.S.-born women (OR 0.41 for Chinese, 0.38 for Filipino, and 0.59 for all Asian women combined).
Public health intervention efforts should take into account Asian ethnic subgroup, gender, and acculturation status in targeting high-risk smoking groups.
PMCID: PMC1853263  PMID: 15917070
Population-based survey; Smoking; Asian American; Correlates
12.  Dramatic Increases in Obesity and Overweight Prevalence among Asian Subgroups in the United States, 1992–2011 
ISRN Preventive Medicine  2013;2013:898691.
We examined trends in adult obesity and overweight prevalence among major Asian/Pacific Islander (API) subgroups and the non-Hispanic whites from 1992 to 2011. Using 1992–2011 National Health Interview Surveys, obesity, overweight, and BMI differentials were analyzed by logistic, linear, and log-linear regression. Between 1992 and 2011, obesity prevalence doubled for the Chinese, the Asian Indians, the Japanese, and the Hawaiians/Pacific Islanders; and tripled for the Filipinos. Obesity prevalence among API adults tripled from 3.7% in 1992 to 13.3% in 2010, and overweight prevalence doubled from 23.2% to 43.1%. Immigrants in each API subgroup had lower prevalence than their US-born counterparts, with immigrants' obesity and overweight risks increasing with increasing duration of residence. During 2006–2011, obesity prevalence ranged from 3.3% for Chinese immigrants to 22.3% for the US-born Filipinos and 41.1% for the Native Hawaiians/Pacific Islanders. The Asian Indians, the Filipinos, and the Hawaiians/Pacific Islanders had, respectively, 3.1, 3.8, and 10.9 times higher odds of obesity than those of the Chinese adults. Compared with Chinese immigrants, the adjusted odds of obesity were 3.5–4.6 times higher for the US-born Chinese and the foreign-born Filipinos, 9 times higher for the US-born Filipinos and whites, 3.8–5.5 times higher for the US-born and foreign-born Asian Indians, and 21.9 times higher for the Native Hawaiians. Substantial ethnic heterogeneity and rising prevalence underscore the need for increased monitoring of obesity and obesity-related risk factors among API subgroups.
PMCID: PMC4045452  PMID: 24967142
13.  Physician visits and preventive care among Asian American and Pacific Islander long-term survivors of colorectal cancer, USA, 1996–2006 
Published literature on receipt of preventive healthcare services among Asian American and Pacific Islander (API) cancer survivors is scarce. We describe patterns in receipt of preventive services among API long-term colorectal cancer (CRC) survivors.
Surveillance, Epidemiology, and End Results registry–Medicare data were used to identify 9,737 API and white patients who were diagnosed with CRC during 1996–2000 and who survived 5 or more years beyond their diagnoses. We examined receipt of vaccines, mammography (females), bone densitometry (females), and cholesterol screening among the survivors and how the physician specialties they visited for follow-up care correlated to services received.
APIs were less likely than whites to receive mammography (52.0 vs. 69.3 %, respectively; P <0.0001) but more likely to receive influenza vaccine, cholesterol screening, and bone densitometry. These findings remained significant in our multivariable model, except for receipt of bone densitometry. APIs visited PCPs only and both PCPs and oncologists more frequently than whites (P <0.0001). Women who visited both PCPs and oncologists compared with PCPs only were more likely to receive mammography (odds ratio=1.40; 95 % confidence interval, 1.05–1.86).
Visits to both PCPs and oncologists were associated with increased use of mammography. Although API survivors visited these specialties more frequently than white survivors, API women may need culturally appropriate outreach to increase their use of this test.
Implications for Cancer Survivors
Long-term cancer survivors need to be aware of recommended preventive healthcare services, as well as who will manage their primary care and cancer surveillance follow-up.
PMCID: PMC4538926  PMID: 24190589
Cancer survivors; Colorectal cancer; Preventive care; Physician specialty
14.  Lung Cancer Occurrence in Never-Smokers: An Analysis of 13 Cohorts and 22 Cancer Registry Studies  
PLoS Medicine  2008;5(9):e185.
Better information on lung cancer occurrence in lifelong nonsmokers is needed to understand gender and racial disparities and to examine how factors other than active smoking influence risk in different time periods and geographic regions.
Methods and Findings
We pooled information on lung cancer incidence and/or death rates among self-reported never-smokers from 13 large cohort studies, representing over 630,000 and 1.8 million persons for incidence and mortality, respectively. We also abstracted population-based data for women from 22 cancer registries and ten countries in time periods and geographic regions where few women smoked. Our main findings were: (1) Men had higher death rates from lung cancer than women in all age and racial groups studied; (2) male and female incidence rates were similar when standardized across all ages 40+ y, albeit with some variation by age; (3) African Americans and Asians living in Korea and Japan (but not in the US) had higher death rates from lung cancer than individuals of European descent; (4) no temporal trends were seen when comparing incidence and death rates among US women age 40–69 y during the 1930s to contemporary populations where few women smoke, or in temporal comparisons of never-smokers in two large American Cancer Society cohorts from 1959 to 2004; and (5) lung cancer incidence rates were higher and more variable among women in East Asia than in other geographic areas with low female smoking.
These comprehensive analyses support claims that the death rate from lung cancer among never-smokers is higher in men than in women, and in African Americans and Asians residing in Asia than in individuals of European descent, but contradict assertions that risk is increasing or that women have a higher incidence rate than men. Further research is needed on the high and variable lung cancer rates among women in Pacific Rim countries.
Michael Thun and colleagues pooled and analyzed comprehensive data on lung cancer incidence and death rates among never-smokers to examine what factors other than active smoking affect lung cancer risk.
Editors' Summary
Every year, more than 1.4 million people die from lung cancer, a leading cause of cancer deaths worldwide. In the US alone, more than 161,000 people will die from lung cancer this year. Like all cancers, lung cancer occurs when cells begin to divide uncontrollably because of changes in their genes. The main trigger for these changes in lung cancer is exposure to the chemicals in cigarette smoke—either directly through smoking cigarettes or indirectly through exposure to secondhand smoke. Eighty-five to 90% of lung cancer deaths are caused by exposure to cigarette smoke and, on average, current smokers are 15 times more likely to die from lung cancer than lifelong nonsmokers (never smokers). Furthermore, a person's cumulative lifetime risk of developing lung cancer is related to how much they smoke, to how many years they are a smoker, and—if they give up smoking—to the age at which they stop smoking.
Why Was This Study Done?
Because lung cancer is so common, even the small fraction of lung cancer that occurs in lifelong nonsmokers represents a large number of people. For example, about 20,000 of this year's US lung cancer deaths will be in never-smokers. However, very little is known about how age, sex, or race affects the incidence (the annual number of new cases of diseases in a population) or death rates from lung cancer among never-smokers. A better understanding of the patterns of lung cancer incidence and death rates among never-smokers could provide useful information about the factors other than cigarette smoke that increase the likelihood of not only never-smokers, but also former smokers and current smokers developing lung cancer. In this study, therefore, the researchers pooled and analyzed a large amount of information about lung cancer incidence and death rates among never smokers to examine what factors other than active smoking affect lung cancer risk.
What Did the Researchers Do and Find?
The researchers analyzed information on lung cancer incidence and/or death rates among nearly 2.5 million self-reported never smokers (men and women) from 13 large studies investigating the health of people in North America, Europe, and Asia. They also analyzed similar information for women taken from cancer registries in ten countries at times when very few women were smokers (for example, the US in the late 1930s). The researchers' detailed statistical analyses reveal, for example, that lung cancer death rates in African Americans and in Asians living in Korea and Japan (but not among Asians living in the US) are higher than those in people of the European continental ancestry group. They also show that men have higher death rates from lung cancer than women irrespective of racial group, but that women aged 40–59 years have a slightly higher incidence of lung cancer than men of a similar age. This difference disappears at older ages. Finally, an analysis of lung cancer incidence and death rates at different times during the past 70 years shows no evidence of an increase in the lung cancer burden among never smokers over time.
What Do These Findings Mean?
Although some of the findings described above have been hinted at in previous, smaller studies, these and other findings provide a much more accurate picture of lung cancer incidence and death rates among never smokers. Most importantly the underlying data used in these analyses are now freely available and should provide an excellent resource for future studies of lung cancer in never smokers.
Additional Information.
Please access these Web sites via the online version of this summary at
The US National Cancer Institute provides detailed information for patients and health professionals about all aspects of lung cancer and information on smoking and cancer (in English and Spanish)
Links to other US-based resources dealing with lung cancer are provided by MedlinePlus (in English and Spanish)
Cancer Research UK provides key facts about the link between lung cancer and smoking and information about all other aspects of lung cancer
PMCID: PMC2531137  PMID: 18788891
15.  Cancer Mortality among Asians and Pacific Islanders in New York City, 2001–2010 
Journal of Cancer Epidemiology  2013;2013:986408.
Asians and Pacific Islanders' (APIs) leading cause of death is cancer. We compared APIs' age-adjusted cancer mortality rates to other racial/ethnic groups and by API subgroup (i.e., Chinese, Koreans, Asian Indians, and Filipinos) using New York City (NYC) Mortality data and Census Bureau population estimates for 2001–2010. While other racial/ethnic groups' overall cancer mortality rates declined in NYC during the last decade, APIs remained stable. APIs overall had the lowest mortality rates for more common cancer types (i.e., lung, colorectal, breast, and prostate), but the highest mortality rates for certain less common cancers (i.e., nasopharyngeal, stomach, and liver). Chinese New Yorkers' lung cancer death rates were very high compared to other APIs and comparable to non-Hispanic whites (47.1/100,000 versus 49.5/100,000, resp.). Chinese men had much higher nasopharyngeal cancer mortality rates (4.5/100,000 versus 0.3/100,000 for non-Hispanic whites). Korean men had the highest liver and stomach cancer mortality rates (25.3/100,000 and 27.7/100,000, resp., versus 7.9/100,000 and 6.0/100,000 for non-Hispanic whites). Analysis of cancer rates by API subgroup provides the detailed information needed to plan cancer prevention efforts. These findings warrant consideration of targeted cancer mortality prevention efforts for affected subgroups, including hepatitis vaccination, screening, and treatment; smoking cessation; and cancer screening.
PMCID: PMC3876672  PMID: 24454374
16.  Does Preconception Health Differ by Nativity?: Findings from the Los Angeles Mommy and Baby (LAMB) Study 
Maternal and child health journal  2016;20(4):769-777.
To compare certain preconception health (PCH) behaviors and conditions among US-born (USB) and foreign-born (FB) mothers in Los Angeles County (LAC), regardless of race/ethnicity, and to determine if any identified differences vary among Asian/Pacific Islanders (API’s) and Hispanics.
Data are from the 2012 Los Angeles Mommy and Baby (LAMB) study (n=6,252). PCH behaviors included tobacco use, multivitamin use, unintended pregnancy, and contraception use. PCH conditions comprised being overweight/obese, diabetes, asthma, hypertension, gum disease, and anemia. The relationship between nativity and each PCH behavior/ condition was assessed using multivariable logistic regression models.
USB women were more likely than FB women to smoke (AOR=2.12, 95% CI=1.49–3.00), be overweight/obese (AOR=1.57, 95% CI=1.30–1.90), and have asthma (AOR=2.04, 95% CI=1.35–3.09) prior to pregnancy. They were less likely than FB women to use contraception before pregnancy (AOR=0.59, 95% CI=0.49–0.72). USB Hispanics and API’s were more likely than their FB counterparts to be overweight/obese (AOR=1.57, 95% CI=1.23–2.01 and AOR=2.37, 95% CI=1.58–3.56, respectively) and less likely to use contraception (AOR=0.58, 95% CI=0.45–0.74 and AOR= 0.46, 95% CI=0.30–0.71, respectively). USB Hispanic mothers were more likely than their FB counterparts to smoke (AOR=2.47, 95% CI=1.46–4.17), not take multivitamins (AOR=1.30, 95% CI=1.02–1.66), and have asthma (AOR=2.35, 95% CI=1.32–4.21) before pregnancy.
US nativity is linked to negative PCH among LAC women, with many of these associations persisting among Hispanics and API’s. As PCH profoundly impacts maternal and child health across the lifecourse, culturally-appropriate interventions that maintain positive behaviors among FB reproductive-aged women and encourage positive behaviors among USB women should be pursued.
PMCID: PMC4794372  PMID: 26728899
Preconception health; nativity; maternal; child health
17.  Return to Work in Low-Income Latina and Non-Latina White Breast Cancer Survivors: A Three-Year Longitudinal Study 
Cancer  2011;118(6):1664-1674.
Prior research has found an 80% return-to-work rate in mid-income White breast cancer survivors, but little is known about the employment trajectory of low-income minorities or Whites. We set out to compare the trajectories of low-income Latina and non-Latina White survivors and to identify correlates of employment status.
Participants were low-income women who had localized breast cancer, spoke English or Spanish, and were employed at the time of diagnosis. Interviews were conducted 6, 18, and 36 months after diagnosis. Multivariate logistic regression was used to identify independent correlates of employment status at 18 months.
Of 290 participants, 62% were Latina. Latinas were less likely than non-Latina Whites to be working 6 months (27% vs. 49%, p=0.0002) and 18 months (45% vs. 59%, p=0.02) after diagnosis, but at 36 months there was no significant difference (53% vs. 59%, p=0.29). Latinas were more likely to be manual laborers than were non-Latina Whites (p<0.0001). Baseline job type and receipt of axillary node dissection were associated with employment status among Latinas but not non-Latina Whites.
Neither low-income Latinas nor non-Latina Whites approached the 80% rate of return to work seen in wealthier White populations. Latinas followed a protracted return-to-work trajectory compared to non-Latina Whites, and differences in job type appear to have played an important role. Manual laborers may be disproportionately impacted by surgical procedures that limit physical activity. This can inform the development of rehabilitative interventions and may have important implications for the surgical and postsurgical management of patients.
PMCID: PMC3263326  PMID: 22009703
disparities; employment; breast cancer; survivorship
18.  Time to definitive diagnosis of breast cancer in Latina and non-Hispanic white women: the six cities study 
SpringerPlus  2013;2:84.
Time delay after an abnormal screening mammogram may have a critical impact on tumor size, stage at diagnosis, treatment, prognosis, and survival of subsequent breast cancer. This study was undertaken to evaluate disparities between Latina and non-Hispanic white (NHW) women in time to definitive diagnosis of breast cancer after an abnormal screening mammogram, as well as factors contributing to such disparities.
As part of the activities of the National Cancer Institute (NCI)-funded Redes En Acción research network, clinical records of 186 Latinas and 74 NHWs who received abnormal screening mammogram results were reviewed to determine the time to obtain a definitive diagnosis. Data was obtained from participating clinics in six U.S. cities and included demographics, clinical history, and mammogram characteristics. Kaplan-Meier estimates and Cox proportional hazards models were used to test differences in median time to definitive diagnosis by ethnicity after adjusting for clinic site, demographics, and clinical characteristics.
Time-to-event analysis showed that Latinas took 2.2 times longer to reach 50% definitively diagnosed with breast cancer relative to NHWs, and three times longer to reach 80% diagnosed (p=0.001). Latinas’ median time to definitive diagnosis was 60 days compared to 27 for NHWs, a 59% gap in diagnosis rates (adjusted Hazard Ratio [aHR] = 1.59, 95% CI = 1.09, 2.31; p=0.015). BI-RADS-4/5 women’s diagnosis rate was more than twice that of BI-RADS-3 (aHR = 2.11, 95% CI = 1.18, 3.78; p=0.011).
Disparities in time between receipt of abnormal screening result and definitive diagnosis adversely affect Latinas compared to NHWs, and remain significant after adjusting for demographic and clinical variables. With cancer now the leading cause of mortality among Latinos, a greater need exists for ethnically and culturally appropriate interventions like patient navigation to facilitate Latinas’ successful entry into, and progression through, the cancer care system.
PMCID: PMC3601250  PMID: 23519779
Health disparities; Breast cancer screening; Definitive diagnosis; Latinas; Six cities study
19.  US Incidence of Breast Cancer Subtypes Defined by Joint Hormone Receptor and HER2 Status 
In 2010, Surveillance, Epidemiology, and End Results (SEER) registries began collecting human epidermal growth factor 2 (HER2) receptor status for breast cancer cases.
Breast cancer subtypes defined by joint hormone receptor (HR; estrogen receptor [ER] and progesterone receptor [PR]) and HER2 status were assessed across the 28% of the US population that is covered by SEER registries. Age-specific incidence rates by subtype were calculated for non-Hispanic (NH) white, NH black, NH Asian Pacific Islander (API), and Hispanic women. Joint HR/HER2 status distributions by age, race/ethnicity, county-level poverty, registry, stage, Bloom–Richardson grade, tumor size, and nodal status were evaluated using multivariable adjusted polytomous logistic regression. All statistical tests were two-sided.
Among case patients with known HR/HER2 status, 36810 (72.7%) were found to be HR+/HER2−, 6193 (12.2%) were triple-negative (HR−/HER2−), 5240 (10.3%) were HR+/HER2+, and 2328 (4.6%) were HR−/HER2+; 6912 (12%) had unknown HR/HER2 status. NH white women had the highest incidence rate of the HR+/HER2− subtype, and NH black women had the highest rate of the triple-negative subtype. Compared with women with the HR+/HER2− subtype, triple-negative patients were more likely to be NH black and Hispanic; HR+/HER2+ patients were more likely to be NH API; and HR−/HER2+ patients were more likely to be NH black, NH API, and Hispanic. Patients with triple-negative, HR+/HER2+, and HR−/HER2+ breast cancer were 10% to 30% less likely to be diagnosed at older ages compared with HR+/HER2− patients and 6.4-fold to 20.0-fold more likely to present with high-grade disease.
In the future, SEER data can be used to monitor clinical outcomes in women diagnosed with different molecular subtypes of breast cancer for a large portion (approximately 28%) of the US population.
PMCID: PMC4580552  PMID: 24777111
20.  How Do Social Factors Explain Outcomes in Non–Small-Cell Lung Cancer Among Hispanics in California? Explaining the Hispanic Paradox 
Journal of Clinical Oncology  2013;31(28):3572-3578.
Hispanics in the United States have lower age-adjusted mortality resulting from non–small-cell lung cancer (NSCLC) compared with non-Hispanic whites (NHWs). The purpose of this study was to evaluate individual, clinical, and neighborhood factors in survival among Hispanics with NSCLC.
Patients and Methods
We performed a retrospective analysis of NHWs and Hispanics with NSCLC between 1998 and 2007 in the California Cancer Registry (follow-up to December 2009). Kaplan-Meier curves depict survival by nativity for Hispanics with NSCLC. Cox proportional hazards models estimated hazard of mortality by race with adjustment for individual (age, sex, marital status), clinical (histologic grade, surgery, irradiation, chemotherapy), and neighborhood factors (neighborhood socioeconomic status, ethnic enclave).
We included 14,280 Hispanic patients with NSCLC. Foreign-born Hispanics had 15% decreased risk of disease-specific mortality resulting from NSCLC compared with NHWs (hazard ratio [HR], 0.85; 95% CI, 0.83 to 0.88) after adjustment for individual, clinical, and neighborhood factors. After adjustment for individual factors, compared with US-born Hispanics, foreign-born Hispanics had 10% decreased risk of disease-specific mortality (HR, 0.90; 95% CI, 0.87 to 0.96). Clinical and neighborhood factors slightly moderated the survival benefit for foreign-born patients. A modestly more pronounced survival advantage was seen for foreign-born Hispanics living in low socioeconomic and high Hispanic enclave neighborhoods as compared with US-born Hispanics (HR, 0.86; 95% CI, 0.81 to 0.90).
Foreign-born Hispanics with NSCLC have a decreased risk of disease-specific mortality compared with NHWs and US-born Hispanics with NSCLC. Neighborhood factors slightly moderate this survival advantage. This survival advantage is slightly more pronounced in lower socioeconomic and higher Hispanic enclave neighborhoods.
PMCID: PMC3782149  PMID: 23960183
21.  Cancer incidence in the south Asian population of California, 1988–2000 
Although South Asians (SA) form a large majority of the Asian population of U.S., very little is known about cancer in this immigrant population. SAs comprise people having origins mainly in India, Pakistan, Bangladesh and Sri Lanka. We calculated age-adjusted incidence and time trends of cancer in the SA population of California (state with the largest concentration of SAs) between 1988–2000 and compared these rates to rates in native Asian Indians as well as to those experienced by the Asian/Pacific Islander (API) and White, non-Hispanic population (NHW) population of California.
Age adjusted incidence rates observed among the SA population of California during the time period 1988–2000 were calculated. To correctly identify the ethnicity of cancer cases, 'Nam Pehchan' (British developed software) was used to identify numerator cases of SA origin from the population-based cancer registry in California (CCR). Denominators were obtained from the U.S. Census Bureau. Incidence rates in SAs were calculated and a time trend analysis was also performed. Comparison data on the API and the NHW population of California were also obtained from CCR and rates from Globocan 2002 were used to determine rates in India.
Between 1988–2000, 5192 cancers were diagnosed in SAs of California.
Compared to rates in native Asian Indians, rates of cancer in SAs in California were higher for all sites except oropharyngeal, oesophageal and cervical cancers. Compared to APIs of California, SA population experienced more cancers of oesophagus, gall bladder, prostate, breast, ovary and uterus, as well as lymphomas, leukemias and multiple myelomas. Compared to NHW population of California, SAs experienced more cancers of the stomach, liver and bile duct, gall bladder, cervix and multiple myelomas. Significantly increasing time trends were observed in colon and breast cancer incidence.
SA population of California experiences unique patterns of cancer incidence most likely associated with acculturation, screening and tobacco habits. There is need for early diagnosis of leading cancers in SA. If necessary steps are not taken to curb the growth of breast, colon and lung cancer, rates in SA will soon approximate those of the NHW population of California.
PMCID: PMC1315316  PMID: 16283945
22.  Decreasing Disparity in Liver Transplantation among White and Asian Patients with Hepatocellular Carcinoma, California, 1998–2005 
Cancer  2008;113(8):2173-2179.
A preliminary study using national cancer surveillance data from 1998–2002 suggested there were significant differences between non-Hispanic whites (“whites”) and Asian/Pacific Islanders (APIs) in the use of liver transplantation as a treatment for hepatocellular carcinoma (HCC).
We conducted a study to examine whether differences in liver transplantation between white and API HCC patients were changing over time. Using a population-based statewide cancer registry, we obtained data on all HCC cases diagnosed in California between 1998 and 2005, but limited the study to white and API patients with non-metastatic HCC, sized ≤ 5.0 cm (n = 1728).
During 1998–2003 (n = 1051), the odds of receiving a liver transplant were 2.56 times higher for white patients than for API patients (95% confidence interval [CI], 1.72 to 3.80 times higher), even after adjusting for age, sex, marital status, year of diagnosis, TNM stage, and tumor grade. In contrast, during 2004–2005 (n = 677), there were no significant differences in the odds of receiving a transplant. Between 2002 and 2004, changes in liver transplantation policy assigned priority points to HCC patients (initially to stage I and II, then to stage II only). After the policy changes, API HCC patients experienced a significant increase in stage II diagnoses, while white patients did not.
In California, there was a large and significant disparity in liver transplantation among white and API patients with HCC during 1998–2003, but not during 2004–2005. Changes in liver transplantation policy during 2002–2004 may have played a role in decreasing this difference.
PMCID: PMC4280013  PMID: 18792066
hepatocellular carcinoma; liver transplantation; whites; Asians
23.  Genetic ancestry and risk of mortality among U.S. Latinas with breast cancer 
Cancer research  2013;73(24):7243-7253.
Multiple studies have reported that Latina women in the U.S. are diagnosed with breast cancer at more advanced stages and have poorer survival than non-Latina White women. However, Latinas are a heterogeneous group with individuals having different proportions of European, Indigenous American and African genetic ancestry. In this study we evaluated the association between genetic ancestry and survival after breast cancer diagnosis among 899 Latina women from the San Francisco Bay Area. Genetic ancestry was estimated from single nucleotide polymorphisms from an Affymetrix 6.0 array and we used Cox proportional hazards models to evaluate the association between genetic ancestry and breast cancer-specific mortality (tests were two-sided). Women were followed for an average of 9 years during which 75 died from breast cancer. Our results showed that Individuals with higher Indigenous American ancestry had increased risk of breast cancer-specific mortality [hazard ratio (HR): 1.57 per 25% increase in Indigenous American ancestry; 95% confidence interval (CI): 1.08–2.29]. Adjustment for demographic factors, tumor characteristics, and some treatment information did not explain the observed association [HR: 1.75, 95%CI: 1.12–2.74]. In an analysis in which ancestry was dichotomized, the hazard of mortality showed a two-fold increase when comparing women with <50% Indigenous American ancestry to women with ≥50% [HR: 1.89, 95%CI: 1.10–3.24]. This was also reflected by Kaplan-Meier survival estimates (P for Log-Rank test of 0.003). Overall, results suggest that genetic factors and/or unmeasured differences in treatment or access to care should be further explored to understand and reduce ethnic disparities in breast cancer outcomes.
PMCID: PMC3881587  PMID: 24177181
Breast cancer mortality; U.S. Latinas; Genetic ancestry
24.  Obesity and Mortality After Breast Cancer by Race/Ethnicity: The California Breast Cancer Survivorship Consortium 
American Journal of Epidemiology  2013;179(1):95-111.
We investigated body size and survival by race/ethnicity in 11,351 breast cancer patients diagnosed from 1993 to 2007 with follow-up through 2009 by using data from questionnaires and the California Cancer Registry. We calculated hazard ratios and 95% confidence intervals from multivariable Cox proportional hazard model–estimated associations of body size (body mass index (BMI) (weight (kg)/height (m)2) and waist-hip ratio (WHR)) with breast cancer–specific and all-cause mortality. Among 2,744 ascertained deaths, 1,445 were related to breast cancer. Being underweight (BMI <18.5) was associated with increased risk of breast cancer mortality compared with being normal weight in non-Latina whites (hazard ratio (HR) = 1.91, 95% confidence interval (CI): 1.14, 3.20), whereas morbid obesity (BMI ≥40) was suggestive of increased risk (HR = 1.43, 95% CI: 0.84, 2.43). In Latinas, only the morbidly obese were at high risk of death (HR = 2.26, 95% CI: 1.23, 4.15). No BMI–mortality associations were apparent in African Americans and Asian Americans. High WHR (quartile 4 vs. quartile 1) was associated with breast cancer mortality in Asian Americans (HR = 2.21, 95% CI: 1.21, 4.03; P for trend = 0.01), whereas no associations were found in African Americans, Latinas, or non-Latina whites. For all-cause mortality, even stronger BMI and WHR associations were observed. The impact of obesity and body fat distribution on breast cancer patients' risk of death may vary across racial/ethnic groups.
PMCID: PMC3864715  PMID: 24107615
adiposity; body mass index; breast cancer; mortality; obesity; race/ethnicity; survival; waist-hip ratio
25.  Knowledge, Awareness and Medical Practice of Asian Americans/Pacific Islanders on Chronic Hepatitis B Infection 
Pogon sahoe yon'gu  2011;31(3):341-364.
The purpose of this review is to conduct a concise review of the literature to evaluate the knowledge, awareness, and medical practice of Asian Americans/Pacific Islanders (API) supporting the relationship of chronic hepatitis B infection. Liver cancer is the fifth most common cause of cancer death in men and the ninth most common cause of death in women in the United States. On average, Asian Americans are three times more likely to die from liver cancer than other racial/ethnic groups, with Chinese Americans at six times, Koreans eight times and Vietnamese 13 times higher than non-Hispanic Whites. In the United States, about 80% of liver cancer is etiologically associated with hepatitis B virus (HBV) infection. Asian Americans and Pacific Islanders (API) account for over half of the 1.3 million chronic hepatitis B cases and for over half of the deaths resulting from chronic hepatitis B infection. Relevant studies were identified in PubMed (Medline) using the following search structure: (Hepatitis B or synonyms) AND (liver cancer or synonyms) AND (Asian Americans or synonyms). Further studies were identified by citations in retrieved papers and by consultation with experts. Twenty publications were included in this review. Compared to other racial/ethnic groups, Asians, especially those born in China or Southeast Asia, have significantly poorer knowledge regarding hepatitis B and liver cancer. Knowledge, awareness and medical practice among Asian Americans regarding HBV infection were dependent upon age, gender, race/ethnicity, immigrant status and length of residency. Despite increased risk for chronic hepatitis B and liver cancer, many Asian Americans are uninformed, untested, and unprotected against the disease.
PMCID: PMC4139091  PMID: 25152650
Knowledge; Awareness and Medical Practice; Hepatitis B; Liver Cancer; Asian Americans; Pacific Islanders

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