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1.  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
2.  Impact of neighborhood and individual socioeconomic status on survival after breast cancer varies by race/ethnicity: The Neighborhood and Breast Cancer Study 
Research is limited on the independent and joint effects of individual- and neighborhood-level socioeconomic status (SES) on breast cancer survival across different racial/ethnic groups.
We studied individual-level SES, measured by self-reported education, and a composite neighborhood SES (nSES) measure in females (1,068 non-Hispanic whites, 1,670 Hispanics, 993 African-Americans, and 674 Asian-Americans), aged 18–79 years and diagnosed 1995–2008, in the San Francisco Bay Area. We evaluated all-cause and breast cancer-specific survival using stage-stratified Cox proportional hazards models with cluster adjustment for census block groups.
In models adjusting for education and nSES, lower nSES was associated with worse all-cause survival among African-Americans (p-trend=0.03), Hispanics (p-trend=0.01) and Asian-Americans (p-trend=0.01). Education was not associated with all-cause survival. For breast cancer-specific survival, lower nSES was associated with poorer survival only among Asian-Americans (p-trend=0.01). When nSES and education were jointly considered, women with low education and low nSES had 1.4 to 2.7-times worse all-cause survival than women with high education and high nSES across all races/ethnicities. Among African-Americans and Asian-Americans, women with high education and low nSES had 1.6 to 1.9-times worse survival, respectively. For breast cancer-specific survival, joint associations were found only among Asian-Americans with worse survival for those with low nSES regardless of education.
Both neighborhood and individual SES are associated with survival after breast cancer diagnosis, but these relationships vary by race/ethnicity.
A better understanding of the relative contributions and interactions of SES with other factors will inform targeted interventions towards reducing long-standing disparities in breast cancer survival.
PMCID: PMC4018239  PMID: 24618999
breast cancer survival; neighborhood socioeconomic status; education; race/ethnicity
3.  Heterogeneity of breast cancer subtypes and survival among Hispanic women with invasive breast cancer in California 
There are limited data regarding breast cancer subtypes among Hispanic women. The current study assessed the distribution and prognosis of molecular subtypes defined by joint expression of the hormone receptors (HR; estrogen and progesterone) and human epidermal growth factor receptor 2 (HER2).
Using California Cancer Registry data, we identified Hispanic women diagnosed with invasive breast cancer from 2005–2010. Breast cancer subtypes were defined as HR+/HER2−, HR+/HER2+, HR−/HER2+, and HR−/HER2− (triple negative). We estimated breast cancer subtype frequencies and used polytomous logistic regression, Kaplan Meier survival plots and Cox regression to examine differences in relation to demographic and clinical characteristics.
Among 16,380 Hispanic women with breast cancer, HR+/HER− subtype was most common (63%), followed by triple negative (16%), HR+/HER2+ (14%) and HR−/HER2+ (8%). Women in lower SES neighborhoods had greater risk of triple negative and HR−/HER2+ subtypes relative to HR+/HER2− (p<0.05). Hispanic women with triple negative and HR−/HER2+ tumors experienced poorer survival than those with HR+/HER− tumors. Breast cancer-specific mortality increased with decreasing SES, relative to the highest SES quintile, from HR=1.38 for quintile 4 to HR=1.76 for quintile 1 (lowest SES level).
Our findings indicate that Hispanic women residing in low SES neighborhoods had significantly increased risk of developing and dying from HR− than HR+ breast cancers. Similar patterns of subtype frequency and prognosis among California Hispanic women and studies of other racial/ethnic groups underscore the need to better understand the impact of SES on risk factor exposures that increase the risk of breast cancer subtypes with poor prognosis.
PMCID: PMC4045012  PMID: 24658879
breast cancer; Hispanic; Latina; socioeconomic status; triple negative
4.  Asian ethnicity and breast cancer subtypes: a study from the California Cancer Registry 
The distribution of breast cancer molecular subtypes has been shown to vary by race/ethnicity, highlighting the importance of host factors in breast tumor biology. We undertook the current analysis to determine population-based distributions of breast cancer subtypes among six ethnic Asian groups in California. We defined immunohistochemical (IHC) surrogates for each breast cancer subtype among Chinese, Japanese, Filipina, Korean, Vietnamese, and South Asian patients diagnosed with incident, primary, invasive breast cancer between 2002 and 2007 in the California Cancer Registry as: hormone receptor-positive (HR+)/HER2− [estrogen receptor-positive (ER+) and/or progesterone receptor-positive (PR+), human epidermal growth factor receptor 2-negative (HER2−)], triple-negative (ER−, PR−, and HER2−), and HER2-positive (ER±, PR±, and HER2+). We calculated frequencies of breast cancer subtypes among Asian ethnic groups and evaluated their associations with clinical and demographic factors. Complete IHC data were available for 8,140 Asian women. Compared to non-Hispanic White women, Korean [odds ratio (OR) = 1.8, 95% confidence interval (CI) = 1.5–2.2], Filipina (OR = 1.3, 95% CI = 1.2–1.5), Vietnamese (OR = 1.3, 95% CI = 1.1–1.6), and Chinese (OR =1.1, 95% CI = 1.0–1.3) women had a significantly increased risk of being diagnosed with HER2-positive breast cancer subtypes after adjusting for age, stage, grade, socioeconomic status, histology, diagnosis year, nativity, and hospital ownership status. We report a significant ethnic disparity in HER2-positive breast cancer in a large population-based cohort enriched for Asian-Americans. Given the poor prognosis and high treatment costs of HER2-positive breast cancer, our results have implications for healthcare resource utilization, cancer biology, and clinical care.
PMCID: PMC4349378  PMID: 20957431
Breast cancer subtypes; Asian; Ethnicity; HER2-positive breast cancer; Hormone receptor-positive breast cancer; Triple-negative breast cancer
5.  Breast Cancer Treatment across Healthcare Systems: Linking Electronic Medical Records and State Registry Data to Enable Outcomes Research 
Cancer  2013;120(1):103-111.
Understanding of cancer outcomes is limited by data fragmentation. We analyzed the information yielded by integrating breast cancer data from three sources: electronic medical records (EMRs) of two healthcare systems and the state registry.
We extracted diagnostic test and treatment data from EMRs of all breast cancer patients treated from 2000–2010 in two independent California institutions: a community-based practice (Palo Alto Medical Foundation) and an academic medical center (Stanford University). We incorporated records from the population-based California Cancer Registry (CCR), and then linked EMR-CCR datasets of Community and University patients.
We initially identified 8210 University patients and 5770 Community patients; linked datasets revealed a 16% patient overlap, yielding 12,109 unique patients. The proportion of all Community patients, but not University patients, treated at both institutions increased with worsening cancer prognostic factors. Before linking datasets, Community patients appeared to receive less intervention than University patients (mastectomy: 37.6% versus 43.2%; chemotherapy: 35% versus 41.7%; magnetic resonance imaging (MRI): 10% versus 29.3%; genetic testing: 2.5% versus 9.2%). Linked Community and University datasets revealed that patients treated at both institutions received substantially more intervention (mastectomy: 55.8%; chemotherapy: 47.2%; MRI: 38.9%; genetic testing: 10.9%; p<0.001 for each three-way institutional comparison).
Data linkage identified 16% of patients who were treated in two healthcare systems and who, despite comparable prognostic factors, received far more intensive treatment than others. By integrating complementary data from EMRs and population-based registries, we obtained a more comprehensive understanding of breast cancer care and factors that drive treatment utilization.
PMCID: PMC3867595  PMID: 24101577
Breast cancer; electronic medical records; bioinformatics; SEER registry; data linkage; outcomes research; comparative effectiveness
6.  Perceptions, Expectations, and Attitudes about Communication with Physicians among Chinese American and non-Hispanic White Women with Early-Stage Breast Cancer 
Asian Americans have consistently reported poorer communication with physicians compared with non-Hispanic Whites (NHW). This qualitative study sought to elucidate the similarities and differences in communication with physicians between Chinese and NHW breast cancer survivors.
Forty-four Chinese and 28 NHW women with early-stage breast cancer (stage 0-IIa) from the Greater Bay Area Cancer Registry participated in focus group discussions or individual interviews. We oversampled Chinese women because little is known about their cancer care experiences. In both interview formats, questions explored patients’ experiences and feelings when communicating with physicians about their diagnosis, treatment, and follow-up care.
Physician empathy at the time of diagnosis was important to both ethnic groups; however, during treatment and follow-up care, physicians’ ability to treat cancer and alleviate physical symptoms was a higher priority. NHW and US-born Chinese survivors were more likely to assert their needs, whereas Chinese immigrants accepted physician advice even when it did not alleviate physical problems (e.g., pain). Patients viewed all physicians as the primary source for information about cancer care. Many Chinese immigrants sought additional information from primary care physicians and stressed optimal communication over language concordance.
Physician empathy and precise information were important for cancer patients. Cultural differences such as the Western emphasis on individual autonomy vs. Chinese emphasis on respect and hierarchy can be the basis for the varied approaches to physician communication we observed. Interventions based on cultural understanding can foster more effective communication between immigrant patients and physicians ultimately improving patient outcomes.
PMCID: PMC4018227  PMID: 23903797
Patient-Physician communication; Chinese Americans; Culture; Breast Cancer
7.  Differences in the cancer burden among foreign-born and US-born Arab Americans living in metropolitan Detroit 
Cancer causes & control : CCC  2013;24(11):1955-1961.
Migrant studies often provide clues for cancer etiology. We estimated the cancer burden among Arab Americans (ArA) by immigrant status in the metropolitan Detroit area, home to one of the highest concentrations of ArA in USA.
A validated name algorithm was used to identify ArA cancer cases diagnosed 1990–2009 in the Detroit SEER database. Recorded birthplace was supplemented with imputation of nativity using birthdate and social security number. Age-adjusted, gender-specific proportional incidence ratios and 95 % confidence intervals were calculated comparing all ArA, foreign-born ArA, and US-born ArA, to non-Hispanic Whites (NHW).
Foreign-born ArA males had higher proportions of multiple myeloma, leukemia, kidney, liver, stomach, and bladder cancer than NHW, while bladder cancer and leukemia were higher among US-born ArA males. For ArA women, gall bladder and thyroid cancers were proportionally higher among both foreign- and US-born compared with NHW. Stomach cancer was proportionally higher only among foreign-born women.
Cancer proportional incidence patterns among ArA show some similarity to other migrant groups, with higher proportional incidences of stomach and liver cancers among foreign-born than US-born. Other patterns, such as tobacco-related cancers among ArA men and gall bladder and thyroid cancers among ArA women, will require more investigation of genetic, epigenetic, and environmental factors.
PMCID: PMC4189086  PMID: 24013772
Arab Americans; Migrant groups; Cancer incidence; Proportional incidence ratios
8.  A Population-Based Observational Study of First-Course Treatment and Survival for Adolescent and Young Adult Females with Breast Cancer 
Young age at breast cancer diagnosis is associated with poor survival. However, little is known about factors associated with first-course treatment receipt or survival among adolescent and young adult (AYA) females aged 15–39 years.
Data regarding 19,906 eligible AYA breast cancers diagnosed in California during 1992–2009 were obtained from the population-based California Cancer Registry. Multivariable logistic regression was used to evaluate clinical and sociodemographic differences in treatment receipt. Multivariable Cox proportional hazards regression was used to examine differences in survival by initial treatment, and by patient and tumor characteristics.
Black and Hispanic AYAs diagnosed with in situ or stages I–III breast cancer were more likely than White AYAs to receive breast-conserving surgery (BCS) without radiation; Asian and Hispanic AYAs were more likely than Whites to receive mastectomy. Women in lower socioeconomic status (SES) neighborhoods were more likely to omit radiation after BCS, more likely to receive mastectomy, and less likely to receive chemotherapy, compared to those in higher SES neighborhoods. Among patients with invasive disease, survival improved an average of 5% per year during 1992–2009. AYAs who received BCS with radiation experienced better survival than other surgery/radiation options. Black AYAs had poorer survival than Whites. AYAs who resided in higher SES neighborhoods had better survival.
Treatment receipt among AYAs with breast cancer varied by race/ethnicity and neighborhood SES. Poor survival for Black AYAs and AYAs living in low SES neighborhoods in models adjusted for treatment receipt suggests that factors other than treatment may also be important to disease outcome.
PMCID: PMC3779013  PMID: 24066271
breast cancer; treatment; survival; race/ethnicity; socioeconomic status
9.  Patterns and predictors of breast cancer chemotherapy use in Kaiser Permanente Northern California, 2004-2007 
Chemotherapy regimens for early stage breast cancer have been tested by randomized clinical trials, and specified by evidence-based practice guidelines. However, little is known about the translation of trial results and guidelines to clinical practice. We extracted individual-level data on chemotherapy administration from the electronic medical records of Kaiser Permanente Northern California (KPNC), a pre-paid integrated healthcare system serving 29% of the local population. We linked data to the California Cancer Registry, incorporating socio-demographic and tumor factors, and performed multivariable logistic regression analyses on the receipt of specific chemotherapy regimens. We identified 6,004 women diagnosed with Stage I–III breast cancer at KPNC during 2004–2007; 2,669 (44.5 %) received at least one chemotherapy infusion at KPNC within 12 months of diagnosis. Factors associated with receiving chemotherapy included age <50 years [odds ratio (OR) 2.27, 95 % confidence interval (CI) 1.81–2.86], tumor >2 cm (OR 2.14, 95 % CI 1.75-2.61), involved lymph nodes (OR 11.3, 95 % CI 9.29–13.6), hormone receptor-negative (OR 6.94, 95% CI 4.89–9.86), Her2/neu-positive (OR 2.71, 95% CI 2.10–3.51), or high grade (OR 3.53, 95 % CI 2.77-4.49) tumors; comorbidities associated inversely with chemotherapy use [heart disease for anthracyclines (OR 0.24, 95 % CI 0.14–0.41), neuropathy for taxanes (OR 0.45, 95 % CI 0.22–0.89)]. Relative to high-socioeconomic status (SES) non-Hispanic Whites, we observed less anthracycline and taxane use by SES non-Hispanic Whites (OR 0.63, 95 % CI 0.49-0.82) and American Indians (OR 0.23, 95 % CI 0.06–0.93), and more anthracycline use by high-SES Asians/Pacific Islanders (OR 1.72, 95 % CI 1.02–2.90). In this equal-access healthcare system, chemotherapy use followed practice guidelines, but varied by race and socio-demographic factors. These findings may inform efforts to optimize quality in breast cancer care.
PMCID: PMC3769522  PMID: 23139057
Breast cancer; Chemotherapy; Patterns of care; Electronic medical record; Disparities; Outcomes research; Quality of care
10.  Impact of breast cancer subtypes on 3-year survival among adolescent and young adult women 
Young women have poorer survival after breast cancer than do older women. It is unclear whether this survival difference relates to the unique distribution of hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2)-defined molecular breast cancer subtypes among adolescent and young adult (AYA) women aged 15 to 39 years. The purpose of our study was to examine associations between breast cancer subtypes and short-term survival in AYA women, as well as to determine whether the distinct molecular subtype distribution among AYA women explains the unfavorable overall breast cancer survival statistics reported for AYA women compared with older women.
Data for 5,331 AYA breast cancers diagnosed between 2005 and 2009 were obtained from the California Cancer Registry. Survival by subtype (triple-negative; HR+/HER2-; HR+/HER2+; HR-/HER2+) and age-group (AYA versus 40- to 64-year-olds) was analyzed with Cox proportional hazards regression with follow-up through 2010.
With up to 6 years of follow-up and a mean survival time of 3.1 years (SD = 1.5 years), AYA women diagnosed with HR-/HER + and triple-negative breast cancer experienced a 1.6-fold and 2.7-fold increased risk of death, respectively, from all causes (HR-/HER + hazard ratio: 1.55; 95% confidence interval (CI): 1.10 to 2.18; triple-negative HR: 2.75; 95% CI, 2.06 to 3.66) and breast cancer (HR-/HER + hazard ratio: 1.63; 95% CI, 1.12 to 2.36; triple-negative hazard ratio: 2.71; 95% CI, 1.98 to 3.71) than AYA women with HR+/HER2- breast cancer. AYA women who resided in lower socioeconomic status neighborhoods, had public health insurance, and were of Black, compared with White, race/ethnicity experienced worse survival. This race/ethnicity association was attenuated somewhat after adjusting for breast cancer subtypes (hazard ratio, 1.33; 95% CI, 0.98 to 1.82). AYA women had similar all-cause and breast cancer-specific short-term survival as older women for all breast cancer subtypes and across all stages of disease.
Among AYA women with breast cancer, short-term survival varied by breast cancer subtypes, with the distribution of breast cancer subtypes explaining some of the poorer survival observed among Black, compared with White, AYA women. Future studies should consider whether distribution of breast cancer subtypes and other factors, including differential receipt of treatment regimens, influences long-term survival in young compared with older women.
PMCID: PMC3978627  PMID: 24131591
11.  The Association Between Neighborhood Characteristics and Body Size and Physical Activity in the California Teachers Study Cohort 
American journal of public health  2011;102(4):689-697.
We considered interactions between physical activity and body mass index (BMI) and neighborhood factors.
We used recursive partitioning to identify predictors of low recreational physical activity (<2.5 hours/week) and overweight and obesity (BMI≥25.0 kg/m2) among 118 315 women in the California Teachers Study. Neighborhood characteristics were based on 2000 US Census data and Reference US business listings.
Low physical activity and being overweight or obese were associated with individual sociodemographic characteristics, including race/ethnicity and age. Among White women aged 36 to 75 years, living in neighborhoods with more household crowding was associated with a higher probability of low physical activity (54% vs 45% to 51%). In less crowded neighborhoods where more people worked outside the home, the existence of fewer neighborhood amenities was associated with a higher probability of low physical activity (51% vs 46%). Among non–African American middle-aged women, living in neighborhoods with a lower socioeconomic status was associated with a higher probability of being overweight or obese (46% to 59% vs 38% in high–socioeconomic status neighborhoods).
Associations between physical activity, overweight and obesity, and the built environment varied by sociodemographic characteristics in this educated population.
PMCID: PMC3410673  PMID: 21852626
12.  Lymphoid malignancies in US Asians: incidence rate differences by birthplace and acculturation 
Malignancies of the lymphoid cells, including non-Hodgkin lymphomas (NHLs), Hodgkin lymphoma (HL) and multiple myeloma (MM), occur at much lower rates in Asians than other racial/ethnic groups in the United States (US). It remains unclear whether these deficits are explained by genetic or environmental factors. To better understand environmental contributions, we examined incidence patterns of lymphoid malignancies among populations characterized by ethnicity, birthplace, and residential neighborhood socioeconomic status (SES) and ethnic enclave status.
We obtained data regarding all Asian patients diagnosed with lymphoid malignancies between 1988 and 2004 from the California Cancer Registry and neighborhood characteristics from US Census data.
While incidence rates of most lymphoid malignancies were lower among Asian than white populations, only follicular lymphoma (FL), chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), and nodular sclerosis (NS) HL rates were statistically significantly lower among foreign-born than US-born Asians, with incidence rate ratios ranging from 0.34 to 0.87. Rates of CLL/SLL and NS HL were also lower among Asian women living in ethnic enclaves or lower-SES neighborhoods than those living elsewhere. Conclusions: These observations support strong roles of environmental factors in the causation of FL, CLL/SLL, and NS HL.
Studying specific lymphoid malignancies in US Asians may provide valuable insight towards understanding their environmental causes.
PMCID: PMC3111874  PMID: 21493873
lymphoid malignancies; Asians; immigration; environmental causes
13.  Survival following non-small cell lung cancer among Asian/Pacific Islander, Latina, and non-Hispanic White women who have never smoked 
Lung cancer is the leading cause of cancer death among US Asian/Pacific Islander (API) and Latina women, despite low smoking prevalence. This study examined survival patterns following non-small cell lung cancer in a population-based sample of lung cancer cases from the San Francisco Bay Area Lung Cancer Study (SFBALCS).
Women diagnosed with lung cancer from 1998–2003 and 2005–2008 and identified through the Greater Bay Area Cancer Registry were telephone-screened for eligibility for the SFBALCS. The screener data were linked to the cancer registry data to determine follow-up. This analysis included 187 non-Hispanic White, 23 US-born Latina, 32 foreign-born Latina, 30 US-born API, and 190 foreign-born API never smokers diagnosed with lung cancer and followed through 2008.
All-cause survival was poorer among APIs (hazard ratio (HR) and 95% confidence interval (CI) = 1.7 (1.0–2.8) among US-born APIs; 1.2 (0.9–1.5) among foreign-born APIs), and Latinas (HR (95% CI) = 2.1 (1.2–3.6) among US-born Latinas; 1.4 (0.9–2.3) among foreign-born Latinas), relative to non-Hispanic Whites. These survival differences were not explained by differences in selected sociodemographic or clinical factors.
Further research should focus on factors such as cultural behaviors, access to or attitudes toward health care, and genetic variations, as possible explanations for these striking racial/ethnic differences.
Latina and API female never smokers diagnosed with lung cancer were up to two-times more likely to die than non-Hispanic Whites, highlighting the need for additional research to identify the underlying reasons for the disparities, as well as heightened clinical awareness.
PMCID: PMC3070404  PMID: 21239685
lung cancer survival; Asian; Latina; Hispanic; never smokers; nativity
14.  “Racial and social class gradients in life expectancy in contemporary California” 
Social science & medicine (1982)  2010;70(9):1373-1380.
Life expectancy, or the estimated average age of death, is among the most basic measures of a population's health. However, monitoring differences in life expectancy among sociodemographically defined populations has been challenging, at least in the United States (US), because death certification does not include collection of markers of socioeconomic status (SES). In order to understand how SES and race/ethnicity independently and jointly affected overall health in a contemporary US population, we assigned a small area-based measure of SES to all 689,036 deaths occurring in California during a three-year period (1999-2001) overlapping the most recent US census. Residence at death was geocoded to the smallest census area available (block group) and assigned to a quintile of a multifactorial SES index. We constructed life tables using mortality rates calculated by age, sex, race/ethnicity and neighborhood SES quintile, and produced corresponding life expectancy estimates. We found a 19.6 (±0.6) year gap in life expectancy between the sociodemographic groups with the longest life expectancy (highest SES quintile of Asian females; 84.9 years) and the shortest (lowest SES quintile of African-American males; 65.3 years). A positive SES gradient in life expectancy was observed among whites and African-Americans but not Hispanics or Asians. Age-specific mortality disparities varied among groups. Race/ethnicity and neighborhood SES had substantial and independent influences on life expectancy, underscoring the importance of monitoring health outcomes simultaneously by these factors. African-American males living in the poorest 20% of California neighborhoods had life expectancy comparable to that reported for males living in developing countries. Neighborhood SES represents a readily available metric for ongoing surveillance of health disparities in the US.
PMCID: PMC2849870  PMID: 20171001
racial disparities; social class disparities; life expectancy; California; population-based; USA; socioeconomic status (SES)
15.  Breast cancer incidence patterns among California Hispanic women: Differences by nativity and residence in an enclave 
Breast cancer incidence is higher in US-born Hispanic women than foreign-born Hispanics, but no studies have examined how these rates have changed over time. To better inform cancer control efforts, we examined incidence trends by nativity and incidence patterns by neighborhood socioeconomic status (SES) and Hispanic enclave (neighborhoods with high proportions of Hispanics or Hispanic immigrants).
Information regarding all Hispanic women diagnosed with invasive breast cancer between 1988 and 2004 were obtained from the California Cancer Registry. Nativity was imputed from Social Security number for the 27% of cases with missing birthplace information. Neighborhood variables were developed from Census data.
From 1988 to 2004, incidence rates for US-born Hispanics were parallel, but lower than, those of non-Hispanic whites, showing an annual 6% decline from 2002 to 2004. Foreign-born Hispanics had an annual 4% increase in incidence rates from 1995 to 1998 and a 1.4% decline thereafter. Rates were 38% higher for US- than foreign-born Hispanics, with elevations more pronounced for localized than regional/distant disease, and for women > 50 years of age. Residence in higher SES and lower Hispanic enclave neighborhoods were independently associated with higher incidence, with Hispanic enclave having a stronger association than SES.
Compared to foreign-born, US-born Hispanic women in California had higher prevalence of breast cancer risk factors, suggesting that incidence patterns largely reflects these differences in risk factors.
Further research is needed to separate the effects of individual- and neighborhood-level factors that impact incidence in this large and growing population.
PMCID: PMC2895619  PMID: 20447917
16.  The influence of nativity and neighborhoods on breast cancer stage at diagnosis and survival among California Hispanic women 
BMC Cancer  2010;10:603.
In the US, foreign-born Hispanics tend to live in socioeconomic conditions typically associated with later stage of breast cancer diagnosis, yet they have lower breast cancer mortality rates than their US-born counterparts. We evaluated the impact of nativity (US- versus foreign-born), neighborhood socioeconomic status (SES) and Hispanic enclave (neighborhoods with high proportions of Hispanics or Hispanic immigrants) on breast cancer stage at diagnosis and survival among Hispanics.
We studied 37,695 Hispanic women diagnosed from 1988 to 2005 with invasive breast cancer from the California Cancer Registry. Nativity was based on registry data or, if missing, imputed from case Social Security number. Neighborhood variables were developed from Census data. Stage at diagnosis was analyzed with logistic regression, and survival, based on vital status determined through 2007, was analyzed with Cox proportional hazards regression.
Compared to US-born Hispanics, foreign-born Hispanics were more likely to be diagnosed at an advanced stage of breast cancer (adjusted odds ratio (OR) = 1.14, 95% confidence interval (CI): 1.09-1.20), but they had a somewhat lower risk of breast cancer specific death (adjusted hazard ratio (HR) = 0.94, 95% CI: 0.90-0.99). Living in low SES and high enclave neighborhoods was associated with advanced stage of diagnosis, while living in a lower SES neighborhood, but not Hispanic enclave, was associated with worse survival.
Identifying the modifiable factors that facilitate this survival advantage in Hispanic immigrants could help to inform specific interventions to improve survival in this growing population.
PMCID: PMC2988754  PMID: 21050464
17.  Availability and accuracy of medical record information on language usage of cancer patients from a multi-ethnic population 
Documentation of language usage in medical settings could be effective in identifying and addressing language barriers and would improve understanding of health disparities.
This study evaluated the availability and accuracy of medical records information on language for 1,664 cancer patients likely to have poor English proficiency. Accuracy was assessed by comparison to language obtained from interview-based research studies.
For patients diagnosed at facilities where information on language was not abstracted electronically, 81.6% had language information in their medical records, most often in admissions documents. For all 37 hospitals, agreement between medical records and interview language was 79.3% overall and was greater for those speaking English than another language.
Language information is widely available in hospital medical records of cancer patients. However, for the data to be useful for research and reducing language barriers in medical care, the information must be collected in a consistent and accurate manner.
PMCID: PMC2889213  PMID: 19685187
cancer; language; epidemiology; medical record
18.  Impact of socioeconomic status on cancer incidence and stage at diagnosis: selected findings from the surveillance, epidemiology, and end results: National Longitudinal Mortality Study 
Cancer causes & control : CCC  2008;20(4):10.1007/s10552-008-9256-0.
Population-based cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute (NCI) are mainly based on medical records and administrative information. Individual-level socioeconomic data are not routinely reported by cancer registries in the United States because they are not available in patient hospital records. The U.S. representative National Longitudinal Mortality Study (NLMS) data provide self-reported, detailed demographic and socioeconomic data from the Social and Economic Supplement to the Census Bureau's Current Population Survey (CPS). In 1999, the NCI initiated the SEER-NLMS study, linking the population-based SEER cancer registry data to NLMS data. The SEER-NLMS data provide a new unique research resource that is valuable for health disparity research on cancer burden. We describe the design, methods, and limitations of this data set. We also present findings on cancer-related health disparities according to individual-level socioeconomic status (SES) and demographic characteristics for all cancers combined and for cancers of the lung, breast, prostate, cervix, and melanoma.
Records of cancer patients diagnosed in 1973–2001 when residing 1 of 11 SEER registries were linked with 26 NLMS cohorts. The total number of SEER matched cancer patients that were also members of an NLMS cohort was 26,844. Of these 26,844 matched patients, 11,464 were included in the incidence analyses and 15,357 in the late-stage diagnosis analyses. Matched patients (used in the incidence analyses) and unmatched patients were compared by age group, sex, race, ethnicity, residence area, year of diagnosis, and cancer anatomic site. Cohort-based age-adjusted cancer incidence rates were computed. The impact of socioeconomic status on cancer incidence and stage of diagnosis was evaluated.
Men and women with less than a high school education had elevated lung cancer rate ratios of 3.01 and 2.02, respectively, relative to their college educated counterparts. Those with family annual incomes less than $12,500 had incidence rates that were more than 1.7 times the lung cancer incidence rate of those with incomes $50,000 or higher. Lower income was also associated with a statistically significantly increased risk of distant-stage breast cancer among women and distant-stage prostate cancer among men.
Socioeconomic patterns in incidence varied for specific cancers, while such patterns for stage were generally consistent across cancers, with late-stage diagnoses being associated with lower SES. These findings illustrate the potential for analyzing disparities in cancer outcomes according to a variety of individual-level socioeconomic, demographic, and health care characteristics, as well as by area measures available in the linked database.
PMCID: PMC2711979  PMID: 19002764
SEER; NLMS; Cancer incidence; Stage; Education; Income; Poverty; Unemployment; SES; Race/ethnicity; Rural/urban; Health disparities; Record linkage
19.  Incidence of lymphoid neoplasms by subtype among six Asian ethnic groups in the United States, 1996–2004 
Cancer causes & control : CCC  2008;19(10):1171-1181.
To establish baseline data for lymphoid neoplasm incidence by subtype for six Asian-American ethnic groups.
Incident rates were estimated by age and sex for six Asian ethnic groups—Asian Indian/Pakistani, Chinese, Filipino, Japanese, Korean, Vietnamese— in five United States cancer registry areas during 1996–2004. For comparison, rates for non-Hispanic Whites were also estimated.
During 1996–2004, Filipinos had the highest (24.0) and Koreans had the lowest incidence (12.7) of total lymphoid neoplasms. By subtype, Vietnamese and Filipinos had the highest incidence for diffuse large B-cell lymphoma (DLBCL) (8.0 and 7.2); Japanese had the highest incidence of follicular lymphoma (2.3). Although a general male predominance of lymphoid neoplasms was observed, this pattern varied by lymphoid neoplasm subtype. Whites generally had higher rates than all Asian ethnic groups for all lymphoid neoplasms and most lymphoma subtypes, although the magnitude of the difference varied by both ethnicity and lymphoma subtype.
The observed variations in incidence patterns among Asian ethnic groups in the United States suggest that it may be fruitful to pursue studies that compare Asian populations for postulated environmental and genetic risk factors.
PMCID: PMC2581633  PMID: 18543071
Lymphoid neoplasms; Asians
20.  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
21.  Lung cancer incidence in never-smokers 
Lung cancer is a leading cause of cancer death worldwide. While smoking remains the predominant cause of lung cancer, lung cancer in never-smokers is an increasingly prominent public health issue. Data on this topic, particularly lung cancer incidence rates in never-smokers, however, are limited.
We review the existing literature on lung cancer incidence and mortality rates among never-smokers and present new data regarding rates in never-smokers from large, population-based cohorts: 1) Nurses’ Health Study, 2) Health Professionals Follow-up Study, 3) California Teachers Study, 4) Multiethnic Cohort Study, 5) Swedish Lung Cancer Register in the Uppsala/Örebro region, and the 6) First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study.
Truncated age-adjusted incidence rates of lung cancer among never-smokers aged 40 to 79 years in these six cohorts ranged from 14.4 to 20.8 per 100,000 person-years in women and 4.8 to 13.7 per 100,000 person-years in men, supporting earlier observations that women are more likely than men to have non-smoking-associated lung cancer. The distinct biology of lung cancer in never-smokers is apparent in differential responses to epidermal growth factor receptor inhibitors and an increased prevalence of adenocarcinoma histology in never-smokers.
Lung cancer in never-smokers is an important public health issue needing further exploration of its incidence patterns, etiology, and biology.
PMCID: PMC2764546  PMID: 17290054
22.  Why do Asian-American women have lower rates of breast conserving surgery: results of a survey regarding physician perceptions 
BMC Public Health  2009;9:246.
US Asian women with early-stage breast cancer are more likely to receive a modified radical mastectomy (MRM) than White women, contrary to clinical recommendations regarding breast conserving treatment (BCT).
We surveyed physicians regarding treatment decision-making for early-stage breast cancer, particularly as it applies to Asian patients. Physicians were identified through the population-based Greater Bay Area Cancer Registry. Eighty (of 147) physicians completed a questionnaire on sociodemographics, professional training, clinical practices, and perspectives on the treatment decision-making processes.
The most important factors identified by physicians in the BCT/MRM decision were clinical in nature, including presence of multifocal disease (86% identified this as being an important factor for selecting MRM), tumor size (71% for MRM, 78% for BCT), cosmetic result (74% for BCT), and breast size (50% for MRM, 55% for BCT). The most important reasons cited for the Asian treatment patterns were patient attitudes toward not needing to preserve the breast (53%), smaller breast sizes (25%), and fear and cultural beliefs (12%).
These survey results suggest that physicians perceive major roles of both clinical and cultural factors in the BCT/MRM decision, but cultural factors may be more relevant in explaining surgical treatment patterns among Asians.
PMCID: PMC2723109  PMID: 19615070

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