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1.  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
2.  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
3.  Genetic Ancestry and Risk of Breast Cancer among US Latinas 
Cancer research  2008;68(23):9723-9728.
US Latinas have a lower incidence of breast cancer compared to non-Latina White women. This difference is partially explained by differences in the prevalence of known risk factors. Genetic factors may also contribute to this difference in incidence. Latinas are an admixed population with most of their genetic ancestry from Europeans and Indigenous Americans. We used genetic markers to estimate the ancestry of Latina breast cancer cases and controls and assessed the association with genetic ancestry, adjusting for reproductive and other risk factors. We typed a set of 106 ancestry informative markers (AIMs) in 440 Latina women with breast cancer and 597 Latina controls from the San Francisco (SF) Bay area and estimated genetic ancestry using a maximum likelihood method. Odds ratios (OR) and 95% confidence intervals (CI) for ancestry modeled as a continuous variable were estimated using logistic regression with known risk factors included as covariates. Higher European ancestry was associated with increased breast cancer risk. The odds ratio for a 25% increase in European ancestry was 1.79 (95% CI: 1.28–2.79, p<0.001). When known risk factors and place of birth were adjusted for, the association with European ancestry was attenuated but remained statistically significant (OR=1.39; 95% CI: 1.06–2.11, p=0.013). Further work is needed to determine if the association is due to genetic differences between populations or possibly due to environmental factors not measured.
PMCID: PMC2674787  PMID: 19047150
Breast cancer; Genetic ancestry; US Latinas; Non-genetic risk factors
4.  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
5.  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
6.  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
7.  European ancestry is positively associated with breast cancer risk in Mexican women 
The incidence of breast cancer is 35% lower in Hispanic women living in the San Francisco Bay Area than in non-Hispanic white women. We have previously described a significant association between genetic ancestry and risk of breast cancer in a sample of US Hispanics/Latinas. We re-tested the association in women residing in Mexico because of the possibility that the original finding may be confounded by US specific unmeasured environmental exposures. We genotyped a set of 106 ancestry informative markers (AIMs) in 846 Mexican women with breast cancer and 1,035 unaffected controls and estimated genetic ancestry using a maximum likelihood method. Odds ratios (OR) and 95% confidence intervals (CI) for ancestry modeled as a categorical and continuous variable were estimated using logistic regression and adjusted for reproductive and other known risk factors. Greater European ancestry was associated with increased breast cancer risk in this new and independent sample of Mexican women residing in Mexico. Compared to women with 0-25% European ancestry, the risk was increased for women with 51-75% and 76-100% European ancestry (OR=1.35, 95% CI: 0.96-1.91 and 2.44, 95% CI: 0.94-6.35 respectively, p for trend=0.044). For every 25% increase in European ancestry (modeled as a continuous variable) there was a 20% increase in risk of breast cancer (95% CI: 1.03-1.41, p=0.019). These results suggest that non-genetic factors play a crucial role in explaining the difference in breast cancer incidence between Latinas and non-Latina white women and it also points out to the possibility of a genetic component to this difference.
PMCID: PMC2852491  PMID: 20332279
Breast cancer; genetic ancestry; Mexican women
8.  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
9.  The effect of system-level access factors on receipt of reconstruction among Latina and white women with DCIS 
Treatment decisions associated with ductal carcinoma in situ (DCIS), including the decision to undergo breast reconstruction, may be more problematic for Latinas due to access and language issues. To help understand the factors that influence patients’ receipt of reconstruction following mastectomy for DCIS, we conducted a population- based study of English- and Spanish-speaking Latina and non-Latina white women from 35 California counties. The objectives of this study were to identify the role of ethnicity and language in the receipt of reconstruction, the relationship between system-level factors and the receipt of reconstruction, and women’s reasons for not undergoing reconstruction. Women aged 18 and older, who self-identified as Latina or non-Latino white and were diagnosed with DCIS between 2002 and 2005 were selected from eight California Cancer Registry (CCR) regions encompassing 35 counties. Approximately 24 months after diagnosis, they were surveyed about their DCIS treatment decisions. Survey data were merged with CCR records to obtain tumor and treatment data. The survey was successfully completed by 745 women, 239 of whom had a mastectomy and represent the sample included in this study. Whites had a higher completion rate than Latinas (67 and 55%, respectively). Analysis included descriptive statistics and logistic regression modeling. Mean age was 54 years. A greater proportion of whites had reconstruction (72%) compared to English-speaking Latinas (69%) and Spanish-speaking Latinas (40%).Multivariate analysis showed thatwomenwho were aged 65 and older, unemployed, and had a lower ratio of plastic surgeons in their county were less likely to have reconstructive surgery after mastectomy. The most frequent reasonsmentioned not to receive reconstruction included lack of importance and desire to avoid additional surgery. Although ethnic/language differences in treatment selection were observed, multivariable analysis suggests that these differences could be explained by differential employment levels and geographic availability of plastic surgeons.
PMCID: PMC3684692  PMID: 21533531
Ductal carcinoma in situ; Latinas; Reconstruction; Treatment decisions
10.  Quality of Cancer Care among Foreign-Born and US-Born Patients with Lung or Colorectal Cancer 
Cancer  2010;116(23):5497-5506.
Disparities in care have been documented for foreign-born cancer patients in the US. However, limited data are available on lung and colorectal cancer. We assessed whether patient-reported quality and receipt of recommended care differed between US-born and foreign-born cancer patients.
We collected surveys and medical records for a population-based cohort including white, Hispanic, and Asian adults (2,205 US-born and 890 foreign-born) with lung or colorectal cancer diagnosed in California during 2003–2005. We used logistic regression to assess the association of nativity with patient-reported quality of care and receipt of recommended treatments (adjuvant chemotherapy for stage III colon cancer, adjuvant chemotherapy and radiation for stage II/III rectal cancer, and curative surgery for stage I/II non-small cell lung cancer). We also assessed whether language explained any differences in care by nativity.
Overall, 46% of patients reported excellent care, but foreign-born patients were less likely than US-born patients to report excellent quality of care (adjusted odds ratio (AOR)=0.80, 95% confidence interval [CI]=0.65–1.00), a difference partly explained by language of survey, an indicator of English proficiency. Rates of recommended therapies ranged from 64% to 85%; foreign-born patients were less likely to receive chemotherapy and radiation for stage II/III rectal cancer (AOR=0.35, 95% CI=0.12–0.99). Rates of other treatments did not differ significantly by nativity.
Foreign-born cancer patients reported lower quality of care and were less likely to receive some cancer therapies than US-born. Better coordination of care and communication about cancer treatments and expanded use of interpreters may lessen these disparities.
PMCID: PMC2974942  PMID: 20672356
lung cancer; colorectal cancer; recommended care; immigrants; satisfaction; quality; disparities; race/ethnicity; Hispanic; Asian
11.  Excess Weight and Physical Health-Related Quality of Life in Postmenopausal Women of Diverse Racial/Ethnic Backgrounds 
Journal of Women's Health  2010;19(8):1449-1458.
Studies of weight and health-related quality of life (HRQOL) generally focus on white populations. This analysis examines the association between clinical weight categories and physical HRQOL in five racial/ethnic groups of older women and determines the extent to which emotional/psychological (social support, caregiver burden) and physical health (diabetes, osteoarthritis) factors modify this relationship.
The cross-sectional analysis, completed in 2007, used baseline data from postmenopausal women enrolled in the Women's Health Initiative (WHI) during the 5-year recruitment period (1993–1998).
Of 161,393 women, 83% were non-Hispanic white, 9% were African American, 4% were Hispanic/Latina, 3% were Asian/Pacific Islander, and <1% were American Indian/Alaska Native. Obesity (body mass index [BMI] ≥30 kg/m2) was most common in non-Asian minority groups. Regression modeling showed higher odds of poor physical HRQOL with increasing weight category in all groups. In the total sample, these odds were at least 6 times as high in women with class 3 obesity as in women of normal weight and were only mildly attenuated after the analysis adjusted for emotional/psychological factors. Further adjustment for physical health factors made odds ratio (OR) estimates drop from 2.36 to 1.59 for class 1 obesity and from 6.96 to 3.71 for class 3 obesity. This pattern generally persisted within each racial/ethnic group.
Heavier weight negatively affects physical HRQOL in postmenopausal women across diverse racial/ethnic backgrounds. Weight-relevant physical health factors have a greater impact on this weight-HRQOL association than do emotional/psychological factors.
PMCID: PMC2941408  PMID: 20629574
12.  Differing beliefs about breast cancer among Latinas and Anglo women. 
Western Journal of Medicine  1996;164(5):405-409.
To improve breast cancer control among Latinas, it is important to understand culturally based beliefs that many influence the way women view this disease. We did a telephone survey of randomly selected Latinas and non-Hispanic white (Anglo) women in Orange County, California, to explore such beliefs using questions from previous national surveys and an ethnographic study of breast cancer. Respondents included 803 Latinas and 422 Anglo women. Latinas were more likely than Anglo women to believe that factors such as breast trauma (71% versus 39%) and breast fondling (27% versus 6%) increased the risk of breast cancer, less likely to know that symptoms such as breast lumps (89% versus 98%) and bloody breast discharge (69% versus 88%) could indicate breast cancer, and more likely to believe that mammograms were necessary only to evaluate breast lumps (35% versus 11%) (P < .01 for each). After adjusting for age, education, employment status, insurance status, and income, logistic regression analysis confirmed that Latino ethnicity and acculturation levels were significant predictors of these beliefs. We conclude that Latinas' beliefs about cancer differ in important ways from those of Anglo women and that these beliefs may reflect the moral framework within which Latinas interpret diseases. These findings are important for the development of culturally sensitive breast cancer control programs and for practicing physicians.
PMCID: PMC1303537  PMID: 8686296
13.  The Effect of Two Church-based Interventions on Breast Cancer Screening Rates Among Medicaid-Insured Latinas 
Preventing Chronic Disease  2005;2(4):A07.
Latinas face disparities in cancer screening rates compared with non-Latina whites. The Tepeyac Project aims to reduce these disparities by using a church-based approach to increase breast cancer screening among Latinas in Colorado. The objective of this study was to compare the effect of two Tepeyac Project interventions on the mammogram rates of Latinas and non-Latina whites enrolled in the Medicaid fee-for-service program.
Two intervention groups were compared: 209 churches in Colorado that received educational printed materials in Spanish and English (the printed statewide intervention) and four churches in the Denver area that received personalized education from promotoras, or peer counselors (the promotora intervention), in addition to the printed statewide intervention. Biennial Medicaid mammogram claim rates in Colorado before the interventions (1998–1999) and after (2000–2001) were used to compare the effect of the interventions on mammogram use among Latinas and non-Latina whites aged 50 to 64 years who were enrolled in the Medicaid fee-for-service program. Adjusted rates were computed using generalized estimating equations.
Small, nonsignificant increases in screening were observed among Latinas exposed to the promotora intervention (from 25% at baseline to 30% at follow-up [P = .30]) as compared with 45% at baseline and 43% at follow-up for the printed statewide intervention (P = .27). Screening among non-Latina whites increased by 6% in the promotora intervention area (from 32% at baseline to 38% at follow-up [P = .40]) and by 3% in the printed statewide intervention (from 41% at baseline to 44% at follow-up [P = .02]). No significant disparities in breast cancer screening were detected between Latinas and non-Latina whites. After adjustment for the confounders by generalized estimating equations, the promotora intervention had a marginally greater impact than the printed statewide intervention in increasing mammogram use among Latinas (generalized estimating equation, P = .07).
A personalized community-based education was only modestly effective in increasing breast cancer screening among Medicaid-insured Latinas. Education alone may not be the answer for this population. The barriers for these Medicaid enrollees must be investigated so that interventions can be tailored to address their needs.
PMCID: PMC1435704  PMID: 16164811
14.  Breast Cancer in Latinas: Gene Expression, Differential Response to Treatments, and Differential Toxicities in Latinas Compared with Other Population Groups 
The Oncologist  2010;15(5):466-475.
This paper reviews the literature on differences in incidence and outcome of breast cancer among Latina compared with white women. Differences in access to medical care, incidence of environmental factors, and genetics and biology of the disease are well documented. Data on the pharmacogenomics of chemotherapy and endocrine therapy response and toxicity are more limited.
Disparities in clinical outcomes of breast cancer have been described among different racial and ethnic groups in the U.S. Convincing data exist showing that Latina women have a lower incidence of breast cancer but a higher breast cancer–related mortality rate compared with white women. Noticeable differences in breast cancer incidence are present even within different Latina subsets with a higher incidence in second- and third-generation women compared with foreign born. An increasing amount of data exists pointing to significant differences in the genetics and biology of breast cancer in Latinas as a significant contributor to the higher mortality, including a higher incidence of triple-negative breast cancers (which do not overexpress HER-2 protein and are negative for estrogen receptors and progesterone receptors). Other social and environmental factors are likely to play a significant role as well, including a lower rate of screening mammography, variable access to medical care, among others. Recent data are inconclusive regarding differences among racial/ethnic groups in the response to chemotherapy. Data on racial/ethnic variations in the pharmacogenomics of chemotherapy, endocrine treatments, and toxicity are more limited, with some data suggesting differences in frequencies of polymorphisms of genes involved in the metabolism of some of these agents. Further studies are needed on this subject.
PMCID: PMC3227981  PMID: 20427382
Access to health care; Breast cancer; Gene expression; Latina; Hispanics
15.  Ductal carcinoma in situ (DCIS): posttreatment follow-up care among Latina and non-Latina White women 
There is a lack of information about posttreatment care among patients with ductal carcinoma in situ (DCIS). This study compares posttreatment care by ethnicity–language and physician specialty among Latina and White women with DCIS.
Latina and White women diagnosed with DCIS between 2002 and 2005 identified through the California Cancer Registry completed a telephone survey in 2006. Main outcomes were breast surveillance, lifestyle counseling, and follow-up physician specialty.
Key results
Of 742 women (396 White, 349 Latinas), most (90 %) had at least one clinical breast exam (CBE). Among women treated with breast-conserving surgery (BCS; N= 503), 76 % had received at least two mammograms. While 92 % of all women had follow-up with a breast specialist, Spanish-speaking Latinas had the lowest specialist follow-up rates (84 %) of all groups. Lifestyle counseling was low with only 53 % discussing exercise, 43 % weight, and 31 % alcohol in relation to their DCIS. In multivariable analysis, Spanish-speaking Latinas with BCS had lower odds of receiving the recommended mammography screening in the year following treatment compared to Whites (OR 0.5; 95 % CI, 0.2–0.9). Regardless of ethnicity–language, seeing both a specialist and primary care physician increased the odds of mammography screening and CBE (OR 1.6; 95 % CI, 1.2–2.3 and OR 1.9; 95 % CI, 1.3–2.8), as well as having discussions about exercise, weight, and alcohol use, compared to seeing a specialist only.
Most women reported appropriate surveillance after DCIS treatment. However, our results suggest less adequate follow-up for Spanish-speaking Latinas, possibly due to language barriers or insurance access.
Implications for Cancer Survivors
Follow-up with a primary care provider in addition to a breast specialist increases receipt of appropriate follow-up for all women.
PMCID: PMC3627346  PMID: 23408106
DCIS; Posttreatment care; Survivorship; Latina; Language barriers; Health disparities
16.  Household Structure, Family Ties, and Psychological Distress among US-born and Immigrant Latino Women 
Latino women endorse the highest rates of past-month depressive symptoms relative to Latino men and to non-Latino White men and women. Yet, research into the specific domains of family life that reduce or engender psychological distress among Latinas is sparse. We examine the hypothesis that indicators of household structure and family ties will relate to psychological distress among Latinas in the USA, and that these associations will vary by nativity status. We employed nationally representative data of Latina adults (N = 1,427) from the National Latino and Asian American Study. Nativity-stratified regression analyses revealed that strained family ties (i.e., family burden, family cultural conflict) were associated with greater levels of past-month psychological distress for both US-born and immigrant Latinas. Yet, the effect of household structures on psychological distress differed by nativity status. Adjusting for sociodemographic factors, lower levels of household income were associated with greater psychological distress; and having children/adolescents in the household was associated with lower levels of psychological distress among US-born Latinas. In contrast, for immigrant Latinas, being out of the labor force was associated with greater levels of psychological distress. Results suggest that dynamics of both the household and family context predict differential as well as similar mental health outcomes across segments of the Latina population in the USA. These findings underscore the need to understand the pathways by which different facets of family life—structural and social domains—relate to mental health status among subgroups of Latinas. Our results also have implications for the development of tailored interventions to meet the specific needs of Latinas.
PMCID: PMC3900573  PMID: 23421842
psychological distress; Hispanic; nativity; socioeconomic status; cultural values
17.  Breast cancer interventions serving US-based Latinas: current approaches and directions 
Women's health (London, England)  2013;9(4):335-350.
Despite efforts to reduce morbidity and mortality in breast cancer, Latinas continue to have lower 5-year survival rates than their non-Latina white counterparts. All along the cancer continuum from screening to follow-up of abnormal screening to diagnosis and treatment to survivorship, Latinas fare poorer than non-Latina whites. To close this gap, a number of research projects across the continuum have attempted to improve breast cancer outcomes. In this review, we examine studies that have been carried out in breast cancer along the cancer continuum. We focus not only on randomized, controlled trials, but also on quasi-experimental, and pre- and post-test studies that provided interventions for positive breast cancer outcomes. We examine not only the intervention outcomes, but also the type of intervention targets and type of intervention implementation. In future breast cancer research among Latinas, more emphasis should be placed on the steps in detection and treatment that occur after screening.
PMCID: PMC3969611  PMID: 23826775
breast cancer; breast cancer disparities; cancer control continuum; interventions Latinas
18.  Design and evaluation of a theory-based, culturally relevant outreach model for breast and cervical cancer screening for Latina immigrants 
Ethnicity & disease  2012;22(3):274-280.
Breast and cervical cancer are common among Latinas, but screening rates among foreign-born Latinas are relatively low. In this article we describe the design and implementation of a theory-based (PEN-3) outreach program to promote breast and cervical cancer screening to Latina immigrants, and evaluate the program’s effectiveness.
We used data from self-administered questionnaires completed at six annual outreach events to examine the sociodemographic characteristics of attendees and evaluate whether the program reached the priority population – foreign-born Latina immigrants with limited access to health care and screening services. To evaluate the program’s effectiveness in connecting women to screening, we examined the proportion and characteristics of women who scheduled and attended Pap smear and mammography appointments.
Among the 782 Latinas who attended the outreach program, 60% and 83% had not had a Pap smear or mammogram, respectively, in at least a year. Overall, 80% scheduled a Pap smear and 78% scheduled a mammogram. Women without insurance, who did not know where to get screening and had not been screened in the last year were more likely to schedule appointments (p < 0.05). Among women who scheduled appointments, 65% attended their Pap smear and 79% attended the mammogram. We did not identify significant differences in sociodemographic characteristics associated with appointment attendance.
Using a theoretical approach to outreach design and implementation, it is possible to reach a substantial number of Latina immigrants and connect them to cancer screening services.
PMCID: PMC3762980  PMID: 22870569
Cancer screening; community-based participatory research; program evaluation; Latina immigrants
19.  The burden of liver cancer in Asians and Pacific Islanders in the Greater San Francisco Bay Area, 1990 through 2004 
Cancer  2007;109(10):2100-2108.
No previous U.S. study has examined time trends in the incidence rate of liver cancer in the high-risk Asian/Pacific Islander population. We evaluated liver cancer incidence trends in Chinese, Filipino, Japanese, Korean, and Vietnamese males and females in the Greater San Francisco Bay Area of California between 1990 and 2004.
Populations at risk were estimated using the cohort component demographic method. Annual percentage changes (APCs) in age-adjusted incidence rates of primary liver cancer among Asians/Pacific Islanders in the Greater Bay Area Cancer Registry were calculated using joinpoint regression analysis.
The incidence rate of liver cancer between 1990 and 2004 did not change significantly in Asian/Pacific Islander males or females overall. However, the incidence rate declined, albeit statistically non-significantly, in Chinese males (APC =−1.6% [95% confidence interval (CI) =−3.4%, 0.3%], Japanese males (APC = −4.9%, 95% CI =−10.7%, 1.2%), and Japanese females (APC =−3.6%, 95% CI =−8.9%, 2.0%). Incidence rates remained consistently high for Vietnamese, Korean, and Filipino males and females. Trends in the incidence rate of hepatocellular carcinoma were comparable to those for liver cancer. While disparities in liver cancer incidence between Asians/Pacific Islanders and other racial/ethnic groups diminished between 1990–1994 and 2000–2004, those among Asian subgroups increased.
Liver cancer continues to affect Asian/Pacific Islander Americans disproportionately, with consistently high incidence rates in most subgroups. Culturally targeted prevention methods are needed to reduce the high rates of liver cancer in this growing population in the U.S.
PMCID: PMC2777532  PMID: 17385214
Asian Americans; epidemiology; hepatocellular carcinoma; liver cancer; surveillance
20.  Basic demographic and professional characteristics of US women physicians. 
Western Journal of Medicine  1997;166(3):179-184.
Women physicians are a rapidly growing percentage of the physician population in the United States; yet, their fundamental characteristics and largely unknown. The Women Physicians' Health Study is the first large, national study of US women physicians, comprising a random sample (n = 4,501 respondents) of women physicians aged 30 to 70. Data from the Women Physicians' Health Study showed that African-American and Latina or Hispanic physicians were underrepresented, and Asian-American and foreign-born physicians were overrepresented in proportion to their prevalence in the US female population. Women physicians were more likely to be married and less likely to have never married and less likely to have never married or to be divorced or widowed than other US women. Younger physicians were more likely to be residency trained and board-certified and to work more hours per week than older physicians. Younger physicians were also less likely to be in solo practice, government work, or inactive; they tended to be concentrated in group or hospital-based practices. We found that although US women physicians have some common characteristics that differentiate them from other US women, their practice and other characteristics vary substantially by age and specialty in ways that have not previously been reported.
PMCID: PMC1304115  PMID: 9143192
21.  Socioeconomic status and prostate cancer incidence and mortality rates among the diverse population of California 
Cancer Causes & Control   2009;20(8):1431-1440.
The racial/ethnic disparities in prostate cancer rates are well documented, with the highest incidence and mortality rates observed among African-Americans followed by non-Hispanic Whites, Hispanics, and Asian/Pacific Islanders. Whether socioeconomic status (SES) can account for these differences in risk has been investigated in previous studies, but with conflicting results. Furthermore, previous studies have focused primarily on the differences between African-Americans and non-Hispanic Whites, and little is known for Hispanics and Asian/Pacific Islanders.
To further investigate the relationship between SES and prostate cancer among African-Americans, non-Hispanic Whites, Hispanics, and Asian/Pacific Islanders, we conducted a large population-based cross-sectional study of 98,484 incident prostate cancer cases and 8,997 prostate cancer deaths from California.
Data were abstracted from the California Cancer Registry, a population-based surveillance, epidemiology, and end results (SEER) registry. Each prostate cancer case and death was assigned a multidimensional neighborhood-SES index using the 2000 US Census data. SES quintile-specific prostate cancer incidence and mortality rates and rate ratios were estimated using SEER*Stat for each race/ethnicity categorized into 10-year age groups.
For prostate cancer incidence, we observed higher levels of SES to be significantly associated with increased risk of disease [SES Q1 vs. Q5: relative risk (RR) = 1.28; 95% confidence interval (CI): 1.25–1.30]. Among younger men (45–64 years), African-Americans had the highest incidence rates followed by non-Hispanic Whites, Hispanics, and Asian/Pacific Islanders for all SES levels. Yet, among older men (75–84 years) Hispanics, following African-Americans, displayed the second highest incidence rates of prostate cancer. For prostate cancer deaths, higher levels of SES were associated with lower mortality rates of prostate cancer deaths (SES Q1 vs. Q5: RR = 0.88; 95% CI: 0.92–0.94). African-Americans had a twofold to fivefold increased risk of prostate cancer deaths in comparison to non-Hispanic Whites across all levels of SES.
Our findings suggest that SES alone cannot account for the greater burden of prostate cancer among African-American men. In addition, incidence and mortality rates of prostate cancer display different age and racial/ethnic patterns across gradients of SES.
Electronic supplementary material
The online version of this article (doi:10.1007/s10552-009-9369-0) contains supplementary material, which is available to authorized users.
PMCID: PMC2746891  PMID: 19526319
Prostate cancer; Socioeconomic status; Disparities; Incidence rates; Mortality rates
22.  Does socioeconomic disparity in cancer incidence vary across racial/ethnic groups? 
Cancer Causes & Control  2010;21(10):1721-1730.
Very few studies have simultaneously examined incidence of the leading cancers in relation to socioeconomic status (SES) and race/ethnicity in populations including Hispanics and Asians. This study aims to describe SES disparity in cancer incidence within each of four major racial/ethnic groups (non-Hispanic white, black, Hispanic, and Asian/Pacific Islander) for five major cancer sites, including female breast cancer, colorectal cancer, cervical cancer, lung cancer, and prostate cancer.
Invasive cancers of the five major sites diagnosed from 1998 to 2002 (n = 376,158) in California were included in the study. Composite area-based SES measures were used to quantify SES level and to calculate cancer incidence rates stratified by SES. Relative index of inequality (RII) was generated to measure SES gradient of cancer incidence within each racial/ethnic group.
Significant variations were detected in SES disparities across the racial/ethnic groups for all five major cancer sites. Female breast cancer and prostate cancer incidence increased with increased SES in all groups, with the trend strongest among Hispanics. Incidence of cervical cancer increased with decreased SES, with the largest gradient among non-Hispanic white women. Lung cancer incidence increased with decreased SES with the exception of Hispanic men and women, for whom SES gradient was in the opposite direction. For colorectal cancer, higher incidence was associated with lower SES in non-Hispanic whites but with higher SES in Hispanics and Asian/Pacific Islander women.
Examining SES disparity stratified by race/ethnicity enhances our understanding of the complex relationships between cancer incidence, SES, and race/ethnicity.
PMCID: PMC2941051  PMID: 20567897
Cancer incidence; Socioeconomic status; Disparity; Race/ethnicity
23.  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
24.  Latina Patient Perspectives about Informed Treatment Decision Making for Breast Cancer 
Patient education and counseling  2008;73(2):363-370.
To evaluate Latina breast cancer patient perspectives regarding informed decision making related to surgical treatment decision making for breast cancer.
2030 women with non-metastatic breast cancer diagnosed from 8/05-5/06 and reported to the Los Angeles metropolitan SEER registries were mailed a survey shortly after surgical treatment. Latina and African American women were over-sampled. We conducted regression of four decision outcome to evaluate associations between race/ethnicity, demographic and clinical factors, and mechanistic variables (i.e., health literacy) and decision outcomes.
Our analytic sample was 877 women: 24.5% Latina Spanish speaking (Latina-SP), 20.5% Latina English speaking, 24% African American and 26.6% Caucasian. Approximately 28% of women in each ethnic group reported a surgeon-based, 36% a shared, and 36% a patient-based surgery decision. Spanish-preferent Latina women had the greatest odds of high decision dissatisfaction and regret controlling for other factors (OR 5.5, 95% CI:2.9, 10.5 and OR 4.1, 95% CI: 2.2,8.0, respectively). Low health literacy was independently associated with dissatisfaction and regret (OR 5.6, 95% CI:2.9, 11.1 and OR 3.5, 95% CI 1.8,7.1, respectively) and slightly attenuated associations between Latina-SP ethnicity and decision outcomes,.
Despite similar clinical outcomes, patients report very different experiences with treatment decision making. Latina women, especially those who prefer Spanish, are vulnerable to poor breast cancer treatment decision outcomes.
Practice implications
Providers need to be aware of the role of ethnicity, acculturation and literacy in breast cancer treatment discussions.
PMCID: PMC3603851  PMID: 18786799
Latina; breast cancer; surgical treatment; decision making; involvement
25.  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

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