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1.  Racial and Ethnic Variations in Lung Cancer Incidence and Mortality: Results From the Women’s Health Initiative 
Journal of Clinical Oncology  2015;34(4):360-368.
This study aimed to evaluate racial/ethnic differences in lung cancer incidence and mortality in the Women’s Health Initiative Study, a longitudinal prospective cohort evaluation of postmenopausal women recruited from 40 clinical centers.
Lung cancer diagnoses were centrally adjudicated by pathology review. Baseline survey questionnaires collected sociodemographic and health information. Logistic regression models estimated incidence and mortality odds by race/ethnicity adjusted for age, education, calcium/vitamin D, body mass index, smoking (status, age at start, duration, and pack-years), alcohol, family history, oral contraceptive, hormones, physical activity, and diet.
The cohort included 129,951 women—108,487 (83%) non-Hispanic white (NHW); 10,892 (8%) non-Hispanic black (NHB); 4,882 (4%) Hispanic; 3,696 (3%) Asian/Pacific Islander (API); 534 (< 1%) American Indian/Alaskan Native; and 1,994 (1%) other. In unadjusted models, Hispanics had 66% lower odds of lung cancer compared with NHW (odds ratio [OR], 0.34; 95% CI, 0.2 to 0.5), followed by API (OR, 0.45; 95% CI, 0.27 to 0.75) and NHB (OR, 0.75; 95% CI, 0.59 to 0.95). In fully adjusted multivariable models, the decreased lung cancer risk for Hispanic compared with NHW women attenuated to the null (OR, 0.59; 95% CI, 0.35 to 0.99). In unadjusted models Hispanic and API women had decreased risk of death compared with NHW women (OR, 0.30 [95% CI, 0.15 to 0.62] and 0.34 [95% CI, 0.16 to 0.75, respectively); however, no racial/ethnic differences were found in risk of lung cancer death in fully adjusted models.
Differences in lung cancer incidence and mortality are associated with sociodemographic, clinical, and behavioral factors. These findings suggest modifiable exposures and behaviors may contribute to differences in incidence of and mortality by race/ethnicity for postmenopausal women. Interventions focused on these factors may reduce racial/ethnic differences in lung cancer incidence and mortality.
PMCID: PMC4872034  PMID: 26700122
2.  Improving Hospital Reporting of Patient Race and Ethnicity—Approaches to Data Auditing 
Health Services Research  2015;50(Suppl 1):1372-1389.
To investigate new metrics to improve the reporting of patient race and ethnicity (R/E) by hospitals.
Data Sources
California Patient Discharge Database (PDD) and birth registry, 2008–2009, Healthcare and Cost Utilization Project’s State Inpatient Database, 2008–2011, cancer registry 2000–2008, and 2010 US Census Summary File 2.
Study Design
We examined agreement between hospital reported R/E versus self-report among mothers delivering babies and a cancer cohort in California. Metrics were created to measure root mean squared differences (RMSD) by hospital between reported R/E distribution and R/E estimates using R/E distribution within each patient’s zip code of residence. RMSD comparisons were made to corresponding “gold standard” facility-level measures within the maternal cohort for California and six comparison states.
Data Collection
Maternal birth hospitalization (linked to the state birth registry) and cancer cohort records linked to preceding and subsequent hospitalizations. Hospital discharges were linked to the corresponding Census zip code tabulation area using patient zip code.
Principal Findings
Overall agreement between the PDD and the gold standard for the maternal cohort was 86 percent for the combined R/E measure and 71 percent for race alone. The RMSD measure is modestly correlated with the summary level gold standard measure for R/E (r = 0.44). The RMSD metric revealed general improvement in data agreement and completeness across states. “Other” and “unknown” categories were inconsistently applied within inpatient databases.
Comparison between reported R/E and R/E estimates using zip code level data may be a reasonable first approach to evaluate and track hospital R/E reporting. Further work should focus on using more granular geocoded data for estimates and tracking data to improve hospital collection of R/E data.
PMCID: PMC4545337  PMID: 26077950
Data auditing; race/ethnicity; gold standard comparisons
3.  The Impact of Neighborhood Social and Built Environment Factors across the Cancer Continuum: Current Research, Methodologic Considerations, and Future Directions 
Cancer  2015;121(14):2314-2330.
Neighborhood social and built environments have been recognized as important contexts in which health is shaped. We review the extent to which these neighborhood factors have been addressed in population-level cancer research, with a scan of the literature for research that focuses on specific social and/or built environment characteristics and association with outcomes across the cancer continuum, including incidence, diagnosis, treatment, survivorship, and survival. We discuss commonalities and differences in methodologies across studies, current challenges in research methodology, and future directions in this research area. The assessment of social and built environment factors in relation to cancer is a relatively new field, with 82% of 34 reviewed papers published since 2010. Across the wide range of social and built environment exposures and cancer outcomes considered by the studies, numerous associations were reported. However, the directions and magnitudes of association varied, due in large part to the variation in cancer sites and outcomes being studied, but also likely due to differences in study populations, geographical region, and, importantly, choice of neighborhood measure and geographic scale. We recommend that future studies consider the life course implications of cancer incidence and survival, integrate secondary and self-report data, consider work neighborhood environments, and further develop analytical and statistical approaches appropriate to the geospatial and multilevel nature of the data. Incorporating social and built environment factors into research on cancer etiology and outcomes can provide insights into disease processes, identify vulnerable populations, and generate results with translational impact of relevance for interventionists and policy makers.
PMCID: PMC4490083  PMID: 25847484
environment; contextual factors; neighborhood; cancer
5.  Cancer Incidence Trends Among Asian American Populations in the United States, 1990–2008 
National cancer incidence trends are presented for eight Asian American groups: Asian Indians/Pakistanis, Chinese, Filipinos, Japanese, Kampucheans, Koreans, Laotians, and Vietnamese.
Cancer incidence data from 1990 through 2008 were obtained from 13 Surveillance, Epidemiology, End Results (SEER) registries. Incidence rates from 1990 through 2008 and average percentage change were computed using SEER*Stat and Joinpoint software. The annual percentage change (APC) in incidence rates was estimated with 95% confidence intervals (95% CIs) calculated for both the rate and APC estimates. Rates for non-Hispanic whites are presented for comparison.
Prostate cancer was the most common malignancy among most groups, followed by lung, colorectal, liver, and stomach cancers. Breast cancer was generally the most common cancer in women, followed by colorectal and lung cancers; liver, cervix, thyroid, and stomach cancers also ranked highly. Among men, increasing trends were observed for prostate (Asian Indians and Pakistanis: APC 1990–2003 = 2.2, 95% CI = 0.3 to 4.1; Filipinos: APC 1990–1994 = 19.0, 95% CI = 4.5 to 35.4; Koreans: APC 1990–2008 = 2.9, 95% CI = 1.8 to 4.0), colorectal (Koreans: APC 1990–2008 = 2.2, 95% CI = 0.9 to 3.5), and liver cancers (Filipinos: APC 1990–2008 = 1.6, 95% CI = 0.4 to 2.7; Koreans: APC 1990–2006 = 2.1, 95% CI = 0.4 to 3.7; Vietnamese: APC 1990–2008 = 1.6, 95% CI = 0.3 to 2.8), whereas lung and stomach cancers generally remained stable or decreased. Among women, increases were observed for uterine cancer (Asian Indians: APC 1990–2008 = 3.0, 95% CI = 0.3 to 5.8; Chinese: APC 2004–2008 = 7.0, 95% CI = 1.4 to 12.9; Filipina: APC 1990–2008 = 3.0, 95% CI = 2.4 to 3.7; Japanese: APC 1990–2008 = 1.1, 95% CI = 0.1 to 2.0), colorectal cancer (Koreans: APC 1990–2008 = 2.8, 95% CI = 1.7 to 3.9; Laotians: APC: 1990–2008 = 5.9, 95% CI = 4.0 to 7.7), lung cancer (Filipinas: APC 1990–2008 = 2.1, 95% CI = 1.4 to 2.8; Koreans: APC 1990–2008 = 2.1, 95% CI = 0.6 to 3.6), thyroid cancer (Filipinas: APC 1990–2008 = 2.5, 95% CI = 1.7 to 3.3), and breast cancer in most groups (APC 1990–2008 from 1.2 among Vietnamese and Chinese to 4.7 among Koreans). Decreases were observed for stomach (Chinese and Japanese), colorectal (Chinese), and cervical cancers (Laotians and Vietnamese).
These data fill a critical knowledge gap concerning the cancer experience of Asian American groups and highlight where increased preventive, screening, and surveillance efforts are needed—in particular, lung cancer among Filipina and Korean women and Asian Indian/Pakistani men, breast cancer among all women, and liver cancer among Vietnamese, Laotian, and Kampuchean women and Filipino, Kampuchean, and Vietnamese men.
PMCID: PMC3735462  PMID: 23878350
6.  Patient, hospital, and neighborhood factors associated with treatment of early-stage breast cancer among Asian American women in California 
Clinical guidelines recommend breast conserving surgery (BCS) with radiation as a viable alternative to mastectomy for treatment of early-stage breast cancer. Yet, Asian Americans (AA) are more likely than other groups to have mastectomy or omit radiation after BCS.
We applied polytomous logistic regression and recursive partitioning (RP) to analyze factors associated with mastectomy, or BCS without radiation, among 20,987 California AAs diagnosed with stage 0–II breast cancer from 1990–2007.
The percentage receiving mastectomy ranged from 40% among US-born Chinese to 58% among foreign-born Vietnamese. Factors associated with mastectomy included tumor characteristics such as larger tumor size, patient characteristics such as older age and foreign birthplace among some AA ethnicities, and additional factors including hospital (smaller hospital size, not NCI cancer center, low socioeconomic status (SES) patient composition, and high hospital AA patient composition) and neighborhood characteristics (ethnic enclaves of low SES). These hospital and neighborhood characteristics were also associated with BCS without radiation. Through RP, the highest mastectomy subgroups were defined by tumor characteristics such as size and anatomic location, in combination with diagnosis year and nativity.
Tumor characteristics and, secondarily, patient, hospital and neighborhood factors, are predictors of mastectomy and omission of radiation following BCS among AAs.
By focusing on interactions among patient, hospital, and neighborhood factors in the differential receipt of breast cancer treatment, our study identifies subgroups of interest for further study, and translation into public health and patient-focused initiatives to ensure that all women are fully informed about treatment options.
PMCID: PMC3406750  PMID: 22402290
7.  Physical Distress and Cancer Care Experiences Among Chinese-American and Non-Hispanic White Breast Cancer Survivors 
Gynecologic Oncology  2011;124(3):383-388.
The number of Chinese-American breast cancer survivors (BCS) is increasing as a result of increasing incidence rates. There has been little research on Chinese BCS’ follow-up cancer care. This qualitative study aims to understand how Chinese-American BCS experience and cope with physical distress relative to non-Hispanic White (NHW) survivors.
Seventy-one BCS (37 Chinese immigrant, 7 US-born Chinese, 27 NHW) were recruited from the Greater Bay Area Cancer Registry to participate in focus group discussions or one-on-one interviews about their survivorship experiences. All BCS were diagnosed with breast cancer at stage 0-IIA between 2006-2009, and had survived for 1-4 years without recurrence. Interviews were conducted in Cantonese, Mandarin, or English. Data analyses followed established qualitative methods of content analysis.
BCS experienced pain and side effects from radiation, surgery, and hormonal therapy. Physical distress subsequently caused emotional concerns about recurrence or metastasis. Most BCS consulted physicians about their physical distress. Chinese immigrant BCS were less likely to have their issues resolved compared to NHW and US-born Chinese who were more likely to question physicians, ask for referrals, and make repeat attempts if their problems were not resolved. Some Chinese immigrant BCS turned to Traditional Chinese Medicine for relief or accepted the idea that physical distress was part of survivorship.
Chinese immigrant BCS may be at risk for greater distress compared with US-born Chinese and NHW BCS because of cultural norms that make them less inclined to express their needs to physicians or challenge physicians when their needs are not met. Furthermore, they may express symptoms in culturally unique ways (e.g., hot-cold imbalances). Further research is needed to determine how to best improve survivorship care experiences in this understudied population, with the goal of decreasing BCS’ physical distress and improving quality of life.
PMCID: PMC3298543  PMID: 22115854
8.  Intersection of Race/Ethnicity and Socioeconomic Status in Mortality After Breast Cancer 
Journal of community health  2015;40(6):1287-1299.
We investigated social disparities in breast cancer (BC) mortality, leveraging data from the California Breast Cancer Survivorship Consortium. The associations of race/ethnicity, education, and neighborhood SES (nSES) with all-cause and BC-specific mortality were assessed among 9372 women with BC (diagnosed 1993–2007 in California with follow-up through 2010) from four racial/ ethnic groups [African American, Asian American, Latina, and non-Latina (NL) White] using Cox proportional hazards models. Compared to NL White women with high-education/high-nSES, higher all-cause mortality was observed among NL White women with high-education/ low-nSES [hazard ratio (HR) (95 % confidence interval) 1.24 (1.08–1.43)], and African American women with low-nSES, regardless of education [high education HR 1.24 (1.03–1.49); low-education HR 1.19 (0.99–1.44)]. Latina women with low-education/high-nSES had lower all-cause mortality [HR 0.70 (0.54–0.90)] and non-significant lower mortality was observed for Asian American women, regardless of their education and nSES. Similar patterns were seen for BC-specific mortality. Individual- and neighborhood-level measures of SES interact with race/ ethnicity to impact mortality after BC diagnosis. Considering the joint impacts of these social factors may offer insights to understanding inequalities by multiple social determinants of health.
PMCID: PMC4628564  PMID: 26072260
Breast cancer survival; Racial/ethnic disparities; Socioeconomic disparities; Education; Neighborhood socioeconomic status
9.  Hodgkin lymphoma incidence in ethnic enclaves in California 
Leukemia & lymphoma  2015;56(12):3270-3280.
Hodgkin lymphoma (HL) incidence varies with migration and nativity, suggesting an influence of acculturation on risk. In population-based California data including 1,483 Hispanic and 348 Asian/Pacific Islander (API) HL cases, we examined HL rates in residential neighborhoods classified by ethnic enclave status (measuring degree of acculturation) and socioeconomic status (SES). Rates were inversely associated with enclave intensity, although associations varied by gender and race. In females, the enclave effect was stronger in low-SES settings, but rates were higher in less-ethnic/high-SES than more-ethnic/low-SES neighborhoods--diminishing enclave intensity affected rates more than higher SES. In Hispanics, associations were modest, and only females experienced SES modification of rates; in APIs, the enclave effect was much stronger. Thus, acculturation measured by residence in ethnic enclaves affects HL rates independently of neighborhood SES but in complex patterns. Living in less-ethnic neighborhoods may increase HL rates by facilitating social isolation and other gender-specific exposures implicated in risk.
PMCID: PMC4801145  PMID: 25899402
Hodgkin lymphoma; ethnic enclave; acculturation; epidemiology; immigration
10.  Disparities in Breast Cancer Survival Among Asian Women by Ethnicity and Immigrant Status: A Population-Based Study 
American journal of public health  2010;100(5):861-869.
We investigated heterogeneity in ethnic composition and immigrant status among US Asians as an explanation for disparities in breast cancer survival.
We enhanced data from the California Cancer Registry and the Surveillance, Epidemiology, and End Results program through linkage and imputation to examine the effect of immigrant status, neighborhood socioeconomic status, and ethnic enclave on mortality among Chinese, Japanese, Filipino, Korean, South Asian, and Vietnamese women diagnosed with breast cancer from 1988 to 2005 and followed through 2007.
US-born women had similar mortality rates in all Asian ethnic groups except the Vietnamese, who had lower mortality risk (hazard ratio [HR]=0.3; 95% confidence interval [CI]=0.1, 0.9). Except for Japanese women, all foreign-born women had higher mortality than did US-born Japanese, the reference group. HRs ranged from 1.4 (95% CI=1.2, 1.7) among Koreans to 1.8 (95% CI=1.5, 2.2) among South Asians and Vietnamese. Little of this variation was explained by differences in disease characteristics.
Survival after breast cancer is poorer among foreign- than US-born Asians. Research on underlying factors is needed, along with increased awareness and targeted cancer control.
PMCID: PMC2853623  PMID: 20299648
11.  Hidden Breast Cancer Disparities in Asian Women: Disaggregating Incidence Rates by Ethnicity and Migrant Status 
American journal of public health  2010;100(Suppl 1):S125-S131.
We estimated trends in breast cancer incidence rates for specific Asian populations in California to determine if disparities exist by immigrant status and age.
To calculate rates by ethnicity and immigrant status, we obtained data for 1998 through 2004 cancer diagnoses from the California Cancer Registry and imputed immigrant status from Social Security Numbers for the 26% of cases with missing birthplace information. Population estimates were obtained from the 1990 and 2000 US Censuses.
Breast cancer rates were higher among US- than among foreign-born Chinese (incidence rate ratio [IRR] = 1.84; 95% confidence interval [CI] = 1.72, 1.96) and Filipina women (IRR = 1.32; 95% CI=1.20, 1.44), but similar between US- and foreign-born Japanese women. US-born Chinese and Filipina women who were younger than 55 years had higher rates than did White women of the same age. Rates increased over time in most groups, as high as 4% per year among foreign-born Korean and US-born Filipina women. From 2000–2004, the rate among US-born Filipina women exceeded that of White women.
These findings challenge the notion that breast cancer rates are uniformly low across Asians and therefore suggest a need for increased awareness, targeted cancer control, and research to better understand underlying factors.
PMCID: PMC2837454  PMID: 20147696
12.  Contribution of the Neighborhood Environment and Obesity to Breast Cancer Survival: The California Breast Cancer Survivorship Consortium 
Little is known about neighborhood attributes that may influence opportunities for healthy eating and physical activity in relation to breast cancer mortality. We used data from the California Breast Cancer Survivorship Consortium and the California Neighborhoods Data System to examine the neighborhood environment, body mass index, and mortality after breast cancer. We studied 8,995 African American, Asian American, Latina, and non-Latina White women with breast cancer. Residential addresses were linked to the CNDS to characterize neighborhoods. We used multinomial logistic regression to evaluate the associations between neighborhood factors and obesity, and Cox proportional hazards regression to examine associations between neighborhood factors and mortality. For Latinas, obesity was associated with more neighborhood crowding (Quartile 4 (Q4) vs. Q1: Odds Ratio (OR)=3.24; 95% Confidence Interval (CI): 1.50-7.00); breast cancer-specific mortality was inversely associated with neighborhood businesses (Q4 vs. Q1: Hazard Ratio (HR)=0.46; 95% CI: 0.25-0.85) and positively associated with multi-family housing (Q3 vs. Q1: HR=1.98; 95% CI: 1.20-3.26). For non-Latina Whites, lower neighborhood socioeconomic status (SES) was associated with obesity (Quintile 1 (Q1) vs. Q5: OR=2.52; 95% CI: 1.31-4.84), breast cancer-specific (Q1 vs. Q5: HR=2.75; 95% CI: 1.47-5.12), and all-cause (Q1 vs. Q5: HR=1.75; 95% CI: 1.17-2.62) mortality. For Asian Americans, no associations were seen. For African Americans, lower neighborhood SES was associated with lower mortality in a nonlinear fashion. Attributes of the neighborhood environment were associated with obesity and mortality following breast cancer diagnosis, but these associations differed across racial/ethnic groups.
PMCID: PMC4687960  PMID: 26063477
California Breast Cancer Survivorship Consortium; Neighborhood Environment; Body Mass Index; Survival; Mortality
13.  Breast cancer mortality in African-American and non-Hispanic white women by molecular subtype and stage at diagnosis: a population-based study 
Higher breast cancer mortality rates for African-American than non-Hispanic white women are well documented; however, it remains uncertain if this disparity occurs in disease subgroups defined by tumor molecular markers and stage at diagnosis. We examined racial differences in outcome according to subtype and stage in a diverse, population-based series of 103,498 patients.
We obtained data for all invasive breast cancers diagnosed 1/1/2005-12/31/2012 and followed through 12/31/2012 among 93,760 non-Hispanic white and 9,738 African-American women in California. Molecular subtypes were categorized according to tumor expression of hormone receptor (HR, based on estrogen and progesterone receptors) and human epidermal growth factor receptor 2 (HER2). Cox proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for breast cancer-specific mortality.
After adjustment for patient, tumor and treatment characteristics, outcomes were comparable by race for Stage I or IV cancer regardless of subtype, and HR+/HER2+ or HR-/HER2+ cancer regardless of stage. We found substantially higher hazards of breast cancer death among African-American women with Stage II/III HR+/HER2- (HR, 1.31, 95% CI, 1.03-1.65, and HR, 1.39, 95% CI, 1.10-1.75, respectively) and Stage III triple-negative cancers relative to whites.
There are substantial racial/ethnic disparities among patients with Stages II/III HR+/HER2- and Stage III triple-negative breast cancers but not for other subtype and stage.
These data provide insights to assess barriers to targeted treatment (e.g. trastuzumab or endocrine therapy) of particular subtypes of breast cancer among African-American patients.
PMCID: PMC4490947  PMID: 25969506
Disparity; breast cancer; subtype; stage; mortality
14.  History of Recreational Physical Activity and Survival After Breast Cancer 
American Journal of Epidemiology  2015;181(12):944-955.
Recent epidemiologic evidence suggests that prediagnosis physical activity is associated with survival in women diagnosed with breast cancer. However, few data exist for racial/ethnic groups other than non-Latina whites. To examine the association between prediagnosis recreational physical activity and mortality by race/ethnicity, we pooled data from the California Breast Cancer Survivorship Consortium for 3 population-based case-control studies of breast cancer patients (n = 4,608) diagnosed from 1994 to 2002 and followed up through 2010. Cox proportional hazards models provided estimates of the relative hazard ratio for mortality from all causes, breast cancer, and causes other than breast cancer associated with recent recreational physical activity (i.e., in the 10 years before diagnosis). Among 1,347 ascertained deaths, 826 (61%) were from breast cancer. Compared with women with the lowest level of recent recreational physical activity, those with the highest level had a marginally decreased risk of all-cause mortality (hazard ratio = 0.88, 95% confidence interval: 0.76, 1.01) and a statistically significant decreased risk of mortality from causes other than breast cancer (hazard ratio = 0.63, 95% confidence interval: 0.49, 0.80), and particularly from cardiovascular disease. No association was observed for breast cancer–specific mortality. These risk patterns did not differ by race/ethnicity (non-Latina white, African American, Latina, and Asian American). Our findings suggest that physical activity is beneficial for overall survival regardless of race/ethnicity.
PMCID: PMC4462332  PMID: 25925388
breast cancer; mortality; race/ethnicity; recreational physical activity; survival
15.  Patient and provider characteristics associated with colorectal, breast, and cervical cancer screening among Asian Americans 
Routinely recommended screening for breast, cervical, and colorectal cancers can significantly reduce mortality from these types of cancer, yet screening is underutilized among Asians. Surveys rely on self-report and often are underpowered for analysis by Asian ethnicities. Electronic health records include validated (as opposed to recall-based) rates of cancer screening. In this paper we seek to better understand cancer screening patterns in a population of insured Asian Americans.
We calculated rates of compliance with cervical, breast, and colorectal cancer screening among Asians from an EHR population, and compared them to non-Hispanic whites. We performed multivariable modeling to evaluate potential predictors (at the provider- and patient- level) of screening completion among Asian patients.
Aggregation of Asian subgroups masked heterogeneity in screening rates. Asian Indians and Native Hawaiians and Pacific Islanders had the lowest rates of screening in our sample, well below that of non-Hispanic whites. In multivariable analyses, screening completion was negatively associated with patient-physician language discordance for mammography (OR:0.81 95% CI:0.71–0.92) and colorectal cancer screening (OR:0.79 CI:0.72–0.87) and positively associated with patient-provider gender concordance for mammography (OR:1.16 CI:1.00–1.34) and cervical cancer screening (OR:1.66 CI:1.51–1.82). Additionally, patient enrollment in online health services increased mammography (OR:1.32 CI:1.20–1.46) and cervical cancer screening (OR:1.31 CI:1.24–1.37).
Language- and gender- concordant primary care providers, and culturally tailored online health resources may help improve preventive cancer screening in Asian patient populations.
This study demonstrates how use of EHR data can inform investigations of primary prevention practices within the healthcare delivery setting.
PMCID: PMC4221799  PMID: 25368396
cancer screening; racial disparities; Asian Americans; health services; electronic health records
16.  Representativeness of breast cancer cases in an integrated health care delivery system 
BMC Cancer  2015;15:688.
Integrated health care delivery systems, with their comprehensive and integrated electronic medical records (EMR), are well-poised to conduct research that leverages the detailed clinical data within the EMRs. However, information regarding the representativeness of these clinical populations is limited, and thus the generalizability of research findings is uncertain.
Using data from the population-based California Cancer Registry, we compared age-adjusted distributions of patient and neighborhood characteristics for three groups of breast cancer patients: 1) those diagnosed within Kaiser Permanente Northern California (KPNC), 2) non-KPNC patients from NCI-designated cancer centers, and 3) those from all other hospitals.
KPNC patients represented 32 % (N = 36,109); cancer center patients represented 7 % (N = 7805); and all other hospitals represented 61 % (N = 68,330) of the total breast cancer patients from this geographic area during 1996–2009. Compared with cases from all other hospitals, KPNC had slightly fewer non-Hispanic Whites (70.6 % versus 74.4 %) but more Blacks (8.1 % versus 5.0 %), slightly more patients in the 50–69 age range and fewer in the younger and older age groups, a slightly lower proportion of in situ but higher proportion of stage I disease (41.6 % versus 38.9 %), were slightly less likely to reside in the lowest (4.2 % versus 6.5 %) and highest (36.2 % versus 39.0 %) socioeconomic status neighborhoods, and more likely to live in suburban metropolitan areas and neighborhoods with more racial/ethnic minorities. Cancer center patients differed substantially from patients from KPNC and all other hospitals on all characteristics assessed. All differences were statistically significant (p < .001).
Although much of clinical research discoveries are based in academic medical centers, patients from large, integrated medical centers are likely more representative of the underlying population, providing support for the generalizability of cancer research based on electronic data from these centers.
PMCID: PMC4604822  PMID: 26467773
Cancer research network; Electronic medical records; Electronic health records; Comparative effectiveness research; NCI-designated cancer center; Breast cancer
17.  Chromosomal copy number alterations for associations of ductal carcinoma in situ with invasive breast cancer 
Screening mammography has contributed to a significant increase in the diagnosis of ductal carcinoma in situ (DCIS), raising concerns about overdiagnosis and overtreatment. Building on prior observations from lineage evolution analysis, we examined whether measuring genomic features of DCIS would predict association with invasive breast carcinoma (IBC). The long-term goal is to enhance standard clinicopathologic measures of low- versus high-risk DCIS and to enable risk-appropriate treatment.
We studied three common chromosomal copy number alterations (CNA) in IBC and designed fluorescence in situ hybridization-based assay to measure copy number at these loci in DCIS samples. Clinicopathologic data were extracted from the electronic medical records of Stanford Cancer Institute and linked to demographic data from the population-based California Cancer Registry; results were integrated with data from tissue microarrays of specimens containing DCIS that did not develop IBC versus DCIS with concurrent IBC. Multivariable logistic regression analysis was performed to describe associations of CNAs with these two groups of DCIS.
We examined 271 patients with DCIS (120 that did not develop IBC and 151 with concurrent IBC) for the presence of 1q, 8q24 and 11q13 copy number gains. Compared to DCIS-only patients, patients with concurrent IBC had higher frequencies of CNAs in their DCIS samples. On multivariable analysis with conventional clinicopathologic features, the copy number gains were significantly associated with concurrent IBC. The state of two of the three copy number gains in DCIS was associated with a risk of IBC that was 9.07 times that of no copy number gains, and the presence of gains at all three genomic loci in DCIS was associated with a more than 17-fold risk (P = 0.0013).
CNAs have the potential to improve the identification of high-risk DCIS, defined by presence of concurrent IBC. Expanding and validating this approach in both additional cross-sectional and longitudinal cohorts may enable improved risk stratification and risk-appropriate treatment in DCIS.
Electronic supplementary material
The online version of this article (doi:10.1186/s13058-015-0623-y) contains supplementary material, which is available to authorized users.
PMCID: PMC4534146  PMID: 26265211
18.  Diabetes and other comorbidities in breast cancer survival by race/ethnicity: The California Breast Cancer Survivorship Consortium (CBCSC) 
The role of comorbidities in survival of breast cancer patients has not been well studied, particularly in non-white populations.
We investigated the association of specific comorbidities with mortality in a multiethnic cohort of 8,952 breast cancer cases within the California Breast Cancer Survivorship Consortium (CBCSC), which pooled questionnaire and cancer registry data from five California-based studies. In total, 2,187 deaths (1,122 from breast cancer) were observed through December 31, 2010. Using multivariable Cox proportional hazards regression, we estimated hazards ratios (HR) and 95% confidence intervals (CI) for overall and breast cancer-specific mortality associated with previous cancer, diabetes, high blood pressure (HBP), and myocardial infarction (MI).
Risk of breast cancer-specific mortality increased among breast cancer cases with a history of diabetes (HR=1.48, 95% CI=1.18, 1.87) or MI (HR=1.94, 95% CI=1.27–2.97). Risk patterns were similar across race/ethnicity (non-Latina White, Latina, African American and Asian American), body size, menopausal status, and stage at diagnosis. In subgroup analyses, risk of breast cancer-specific mortality was significantly elevated among cases with diabetes who received neither radiation nor chemotherapy (HR=2.11, 95% CI=1.32–3.36); no increased risk was observed among those who received both treatments (HR=1.13, 95% CI= 0.70–1.84) (P interaction= 0.03). A similar pattern was found for MI by radiation and chemotherapy (P interaction=0.09).
These results may inform future treatment guidelines for breast cancer patients with a history of diabetes or MI.
Given the growing number of breast cancer survivors worldwide, we need to better understand how comorbidities may adversely affect treatment decisions and ultimately outcome.
PMCID: PMC4523272  PMID: 25425578
race/ethnicity; diabetes; myocardial infarction; survival; treatment; tumor characteristics; lifestyle factors
19.  Continued rapid increase in thyroid cancer incidence in California: trends by patient, tumor, and neighborhood characteristics 
Thyroid cancer incidence is increasing worldwide. Incorporating 22 years of incidence data through 2009, we extend examination of these trends among a wide array of subgroups defined by patient (age, sex, race/ethnicity, and nativity), tumor (tumor size and stage), and neighborhood (socioeconomic status and residence in ethnic enclaves) characteristics, to identify possible reasons for this increase.
Thyroid cancer incidence data on 10,940 men and 35,147 women were obtained from the California Cancer Registry for 1988–2009. Population data were obtained from the 1990 and 2000 US Census. Incidence rates and 95% confidence intervals (CI) were calculated and incidence trends evaluated using Joinpoint regression to evaluate the timing and magnitude of change (annual percent change (APC) and rate ratios).
The incidence of papillary thyroid cancer continues to increase in both men (APC=5.4, 95% CI: 4.5–6.3 for 1998–2009) and women (APC=3.8, 95% CI: 3.4–4.2 for 1998–2001 and APC=6.3, 95% CI: 5.7–6.9 for 2001–2009). Increasing incidence was observed in all subgroups examined.
While some variation in the magnitude or temporality of the increase in thyroid cancer incidence exists across subgroups, the patterns (1) suggest that changes in diagnostic technology alone do not account for the observed trends and (2) point to the importance of modifiable behavioral, lifestyle, or environmental factors in understanding this epidemic.
Given the dramatic and continued increase in thyroid cancer incidence rates, studies addressing the causes of these trends are critical.
PMCID: PMC4071298  PMID: 24842625
thyroid cancer; incidence rates; temporal trends; surveillance; California
Head & neck  2010;32(10):1336-1344.
Our aim was to determine the incidence rates of head and neck cancer in Vietnamese Californians compared with other Asian and non-Asian Californians.
Age-adjusted incidence rates of head and neck cancer between 1988 and 2004 were computed for Vietnamese Californians compared with other racial/ethnic groups by time period, ethnicity, neighborhood-level socioeconomic status (SES), and sex using data from the population-based California Cancer Registry (CCR). Data by smoking and alcohol status were tabulated from the California Health Interview Survey.
Vietnamese men had a higher incidence rate of head and neck cancer than other Asian men. Specifically, the laryngeal cancer rate was significantly higher for Vietnamese men (6.5/100,000; 95% confidence interval [CI], 5.0–8.2) than all other Asian men (range, 2.6–3.8/100,000), except Korean men (5.1/100,000; 95% CI, 3.9–6.4). Both Vietnamese and Korean men had the highest percentage of current smokers. Neighborhood SES was inversely related to head and neck cancer rates among Vietnamese men and women.
The higher incidence rate of head and neck cancer in Vietnamese men may correspond to the higher smoking prevalence in this group. Individual-level data are needed to establish the link of tobacco, alcohol, and other risk factors with head and neck cancer in these patients.
PMCID: PMC4349526  PMID: 20091688
head and neck cancer; Vietnamese; tobacco; socioeconomic status; immigrant status
21.  Obesity and Mortality After Breast Cancer by Race/Ethnicity: The California Breast Cancer Survivorship Consortium 
American Journal of Epidemiology  2013;179(1):95-111.
We investigated body size and survival by race/ethnicity in 11,351 breast cancer patients diagnosed from 1993 to 2007 with follow-up through 2009 by using data from questionnaires and the California Cancer Registry. We calculated hazard ratios and 95% confidence intervals from multivariable Cox proportional hazard model–estimated associations of body size (body mass index (BMI) (weight (kg)/height (m)2) and waist-hip ratio (WHR)) with breast cancer–specific and all-cause mortality. Among 2,744 ascertained deaths, 1,445 were related to breast cancer. Being underweight (BMI <18.5) was associated with increased risk of breast cancer mortality compared with being normal weight in non-Latina whites (hazard ratio (HR) = 1.91, 95% confidence interval (CI): 1.14, 3.20), whereas morbid obesity (BMI ≥40) was suggestive of increased risk (HR = 1.43, 95% CI: 0.84, 2.43). In Latinas, only the morbidly obese were at high risk of death (HR = 2.26, 95% CI: 1.23, 4.15). No BMI–mortality associations were apparent in African Americans and Asian Americans. High WHR (quartile 4 vs. quartile 1) was associated with breast cancer mortality in Asian Americans (HR = 2.21, 95% CI: 1.21, 4.03; P for trend = 0.01), whereas no associations were found in African Americans, Latinas, or non-Latina whites. For all-cause mortality, even stronger BMI and WHR associations were observed. The impact of obesity and body fat distribution on breast cancer patients' risk of death may vary across racial/ethnic groups.
PMCID: PMC3864715  PMID: 24107615
adiposity; body mass index; breast cancer; mortality; obesity; race/ethnicity; survival; waist-hip ratio
22.  A Mixed Method Exploration of Survivorship among Chinese American and Non-Hispanic White Breast Cancer Survivors: The Role of Socioeconomic Well-Being 
Cancer-related stress is heavily influenced by culture. This study explored similarities and differences in survivorship care concerns among Chinese American and Non-Hispanic White (NHW) breast cancer survivors.
A sequential, mixed-method design (inductive/qualitative research-phase I and deductive/quantitative research-phase II) was employed. Eligible women identified from the Greater Bay Area Cancer Registry were age ≥21, diagnosed with stage 0-IIa breast cancer between 2006–2011, and had no recurrence or other cancers. In phase I, we conducted 4 Chinese (n=19) and 4 NHW (n=22) focus groups, and 31 individual telephone interviews (18 Chinese immigrants, 7 Chinese US-born, and 6 NHW). Content analysis was conducted to examine qualitative data. In phase II, another 296 survivors (148 NHW age-matched to 148 Chinese cases) completed a cross-sectional survey. Descriptive statistics and linear regression analysis were conducted to examine quantitative data.
Qualitative data revealed “socioeconomic wellbeing” (SWB) as a dominant survivorship concern, which was operationalized as a cancer survivor’s perceived economic and social resources available to access care. Quantitative data showed that low-acculturated Chinese immigrants reported the poorest SWB, controlling for covariates. Highly-acculturated Chinese immigrants and the US-born Chinese/NHW group reported similar SWB. Women who had low income levels or chemotherapy had poorer SWB.
SWB emerged as an important aspect of breast cancer survivorship. Immigration stress, cancer care costs, and cultural values all contributed to immigrants’ socioeconomic distress. Immigrant and US-born breast cancer survivors experienced different socioeconomic circumstances and well-being following treatment. Our findings warrant further investigation of socioeconomic distress and survivorship outcomes.
PMCID: PMC3855903  PMID: 23591710
Socioeconomic well-being; Mixed-method; Cancer survivorship; Ethnicity; Chinese Americans; Acculturation
23.  Cancer Incidence Trends Among Native Hawaiians and Other Pacific Islanders in the United States, 1990–2008 
Lack of annual population estimates for disaggregated Native Hawaiian and Other Pacific Islander (NHOPI) populations limits the ability to examine cancer incidence rates and trends to understand the cancer burdens among NHOPIs.
Utilizing 1990 and 2000 population census data, we estimated the annual populations by age and sex for Native Hawaiians, Samoans, and Guamanians/Chamorros for 1990–2008 in regions covered by 13 of the National Cancer Institute’s SEER registries. Cancer diagnoses during 1990–2008 from these registries were used to calculate the age-adjusted (2000 US Standard) incidence rates by sex, calendar year/period, and cancer type for each population. The annual percentage change (APC) in incidence rates was estimated with the 95% confidence intervals (95% CIs) calculated for both the rate and APC estimates.
Statistically significant declining trends were found in Native Hawaiians, in men for lung and stomach cancers (APC = –2.3%; 95% CI = –3.3 to –1.3; and APC = –3.8%; 95% CI = –6.0 to –1.6, respectively), and in women for breast cancer (APC = –4.1%; 95% CI = –5.7 to –2.5) since 1998 and lung cancer (APC = –6.4%; 95% CI = –10.7 to –1.8) since 2001. Rising incidence trends were experienced by Samoans, especially by Samoan women for breast (APC = 2.7%; 95% CI = 0.9 to 4.5) and uterus (APC = 7.3%; 95% CI = 6.2 to 8.4) cancers. With limited data, Guamanians/Chamorros demonstrated lower, but increasing, incidence rates than other NHOPIs.
Population-based cancer incidence rates for disaggregated NHOPI populations help identify disparities in cancer burden and provide valuable information to improve cancer control efforts among NHOPIs.
PMCID: PMC3735461  PMID: 23878354
24.  Prostate Cancer Risk Profiles in Asian Americans: Disentangling the Effects of Immigration Status and Race/Ethnicity 
The Journal of urology  2013;191(4):952-956.
Asian-American men with prostate cancer have been reported to present with higher grade and later stage disease than White Americans. However, Asian Americans comprise a heterogeneous population with distinct health outcomes. We compared prostate cancer risk profiles among the diverse racial and ethnic groups in California.
Materials and Methods
We used data from the California Cancer Registry for 90,845 Non-Hispanic White, Non-Hispanic Black, and Asian-American men diagnosed with prostate cancer between 2004 and 2010. Patients were categorized into low, intermediate, or high-risk groups based on clinical stage, Gleason score, and PSA value at diagnosis. Using polytomous logistic regression, we estimated adjusted odds ratios for the association of race/ethnicity and nativity with risk group.
In addition to Non-Hispanic Blacks, six Asian-American groups (US-born Chinese, foreign-born Chinese, US-born Japanese, foreign-born Japanese, foreign-born Filipino, and foreign-born Vietnamese) were more likely to have an unfavorable risk profile compared to Non-Hispanic Whites. The odds ratios for high vs. intermediate-risk disease ranged from 1.23 (95% CI, 1.02–1.49) for US-born Japanese to 1.45 (95% CI, 1.31–1.60) for foreign-born Filipinos. These associations appeared to be driven by higher grade and PSA values, rather than advanced clinical stage at diagnosis.
In this large, ethnically diverse population-based cohort, we found that Asian-American men were more likely to have unfavorable risk profiles at diagnosis. This association varied by racial/ethnic group and nativity, and was not attributable to later stage at diagnosis, suggesting that Asian men may have biological differences that predispose to the development of more severe disease.
PMCID: PMC4051432  PMID: 24513166
Asian Americans; prostatic neoplasms; epidemiology; SEER Program
25.  The California Breast Cancer Survivorship Consortium (CBCSC): Prognostic factors associated with racial/ethnic differences in breast cancer survival 
Cancer causes & control : CCC  2013;24(10):1821-1836.
Racial/ethnic disparities in mortality among US breast cancer patients are well-documented. Our knowledge of the contribution of lifestyle factors to disease prognosis is based primarily on non-Latina Whites and is limited for Latina, African American and Asian American women. To address this knowledge gap, the California Breast Cancer Survivorship Consortium (CBCSC) harmonized and pooled interview information (e.g., demographics, family history of breast cancer, parity, smoking, alcohol consumption) from six California-based breast cancer studies and assembled corresponding cancer registry data (clinical characteristics, mortality), resulting in 12,210 patients (6,501 non-Latina Whites, 2,060 African Americans, 2,032 Latinas, 1,505 Asian Americans, 112 other race/ethnicity) diagnosed with primary invasive breast cancer between 1993 and 2007. In total, 3,047 deaths (1,570 breast cancer-specific) were observed with a mean (SD) follow-up of 8.3 (3.5) years. Cox-proportional hazards regression models were fit to data to estimate hazards ratios (HR) and 95% confidence intervals (CI) for overall and breast cancer-specific mortality. Compared with non-Latina Whites, the HR of breast cancer-specific mortality was 1.13 (95% CI, 0.97-1.33) for African Americans, 0.84 (95% CI, 0.70-1.00) for Latinas, and 0.60 (95% CI, 0.37-0.97) for Asian Americans after adjustment for age, tumor characteristics, and select lifestyle factors. The CBCSC represents a large and racially/ethnically diverse cohort of breast cancer patients from California. This cohort will enable analyses to jointly consider a variety of clinical, lifestyle, and contextual factors in attempting to explain the long-standing disparities in breast cancer outcomes.
PMCID: PMC4046898  PMID: 23864487
race/ethnicity; survival; tumor characteristics; lifestyle factors

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