Cancer incidence in the Hmong in California, 1988-2000

Survival of the Hmong population diagnosed with colon and rectal cancers in the United States

BACKGROUND

The Hmong population constitutes an independent ethnic group historically dispersed throughout Southeast Asia; fallout from the Vietnam War led to their forced migration to the United States as refugees. This study seeks to investigate characteristics of the Hmong population diagnosed with in colorectal cancer (CRC) as well as survival within this population.

METHODS

Cases of colon and rectal adenocarcinoma diagnosed between 2004 and 2017 were identified from the National Cancer Database (NCDB). Summary statistics of demographic, clinical, socioeconomic, and treatment variables were generated with emphasis on age and stage at the time of diagnosis. Cox-proportional hazard models were constructed for survival analysis.

RESULTS

Of 881,243 total CRC cases within the NCDB, 120 were classified as Hmong. The average age of Hmong individuals at diagnosis was 58.9 years compared 68.7 years for Non-Hispanic White (NHW) individuals (p < 0.01). The distribution of analytic stage differed between the Hmong population and the reference NHW population, with 61.8% of Hmong individuals compared to 45.8% of NHW individuals with known stage being diagnosed at stage III or IV CRC compared to 0, I, or II (p = 0.001). However, there was no difference in OS when adjusting for potential confounders (HR 1.00 [0.77-1.33]; p = 0.998).

CONCLUSIONS

Hmong individuals are nearly a decade younger at the time of diagnosis of CRC compared to the NHW individuals. However, these data do not suggest an association between Hmong ethnicity and overall survival, when compared to the NHW population.

Evaluating Human Papillomavirus eHealth in Hmong Adolescents to Promote Vaccinations: Pilot Feasibility Study

BACKGROUND

Human papillomavirus (HPV) is a common sexually transmitted infection, causing multiple cancers, including cervical, penile, and anal. Infection and subsequent health risks caused by HPV can be diminished by HPV vaccination. Unfortunately, vaccination rates among Hmong Americans are substantially lower than those among other racial and ethnic groups, despite having higher cervical cancer rates than non-Hispanic White women. Such disparities and sparse literature highlight the need for innovative and culturally appropriate educational interventions to improve HPV vaccine rates in Hmong Americans.

OBJECTIVE

We aimed to develop and evaluate the effectiveness and usability of an innovative web-based eHealth educational website, the Hmong Promoting Vaccines website (HmongHPV website), for Hmong-American parents and adolescents to improve their knowledge, self-efficacy, and decision-making capacities to obtain HPV vaccinations.

METHODS

Through social cognitive theory and community-based participatory action research process, we created a theory-driven and culturally and linguistically appropriate website for Hmong parents and adolescents. We conducted a pre-post intervention pilot study to assess the website's effectiveness and usability. Overall, 30 Hmong-American parent and adolescent dyads responded to questions about HPV and HPV vaccine knowledge, self-efficacy, and decision-making at preintervention, 1 week after intervention, and at the 5-week follow-up. Participants responded to survey questions about website content and processes at 1 and 5 weeks, and a subset of 20 dyad participants participated in telephone interviews 6 weeks later. We used paired t tests (2-tailed) to measure the change in knowledge, self-efficacy, and decision-making processes, and used template analysis to identify a priori themes for website usability.

RESULTS

Participants' HPV and HPV vaccine knowledge improved significantly from pre- to postintervention stage and follow-up. Knowledge scores increased from preintervention to 1 week after intervention for both parents (HPV knowledge, P=.01; vaccine knowledge, P=.01) and children (HPV knowledge, P=.01; vaccine knowledge, P<.001), which were sustained at the 5-week follow-up. Parents' average self-efficacy score increased from 21.6 at baseline to 23.9 (P=.007) at post intervention and 23.5 (P=.054) at follow-up. Similar improvements were observed in the teenagers' self-efficacy scores (from 30.3 at baseline to 35.6, P=.009, at post intervention and 35.9, P=.006, at follow-up). Collaborative decision-making between parents and adolescents improved immediately after using the website (P=.002) and at follow-up (P=.02). The interview data also revealed that the website's content was informative and engaging; in particular, participants enjoyed the web-based quizzes and vaccine reminders.

CONCLUSIONS

This theory-driven, community-based participatory action research-designed and culturally and linguistically appropriate educational website was well received. It improved Hmong parents' and adolescents' knowledge, self-efficacy, and decision-making processes regarding HPV vaccination. Future studies should examine the website's impact on HPV vaccine uptake and its potential for broader use across various settings (eg, clinics and schools).

"We will do whatever it takes": Understanding Socioecological Level Influences on Hmong-American Adolescents and Parents' Perceptions of the Human Papillomavirus Vaccine

Human papillomavirus (HPV) vaccination completion rates in Asian-American populations are substantially lower than most White Americans. Our objective was to identify the knowledge, perceptions, and decision-making processes about HPV vaccinations in the Hmong population, an Asian-American group with increased risks of HPV-related cancers. We conducted eight focus groups with Hmong adolescents (n = 12) and parents (n = 13) to learn about barriers, facilitators, and decision-making processes regarding general vaccinations and the HPV vaccine. The focus group results were analyzed using thematic analysis, informed by the socioecological model and asset lens. Findings showed that at the individual level, Hmong adolescents and parents had low HPV and HPV vaccine awareness levels (barrier) and strong desires to learn about HPV and the HPV vaccine (facilitator). Community-level barriers included salient narratives about traumatic experiences with vaccines and vaccine research, while facilitators included strong community connections. At the institutional level, barriers included structural constraints in health care settings, while facilitators included ease of obtaining vaccines at school-based clinics and provider authoritative decision-making. Additionally, a range of decision-making processes between parents, adolescents, and providers were present, with parents expressing a strong appeal to engage in more shared decision-making with providers. A linguistically and culturally specific HPV educational program for Hmong adolescents and parents could address the barriers and build on facilitators and assets to promote HPV vaccine uptake in this growing Asian-American community.

The Asian American Network for Cancer Awareness, Research, and Training (AANCART)'s contributions toward reducing Asian American cancer health disparities, 2000-2017

BACKGROUND

In 2000 and in 2 subsequent 5-year cycles, the National Cancer Institute funded grantees on a regional and national basis to address community needs for cancer awareness, research, and training. The Asian American Network for Cancer Awareness, Research and Training (AANCART) is fortunate to have been funded since 2000 to focus on mitigating cancer health disparities facing Asian Americans residing primarily in California and Hawaii. This article highlights AANCART's achievements with respect to the original specific aims and unanticipated outcomes in its most recent funded cycle.

METHODS

Sources included reports to the National Cancer Institute and peer-reviewed articles as well as the insights of the 3 principal investigators.

RESULTS

All aims of the original application (infrastructure, outreach, research, and training) were attained or exceeded. Most distinctive was the completion and publication of 8 randomized controlled trials to address Asian American cancer health disparities and its nurture of 14 new and early stage investigators who have been productive in terms of research career trajectories.

CONCLUSIONS

AANCART is contributing to mitigating Asian American cancer health disparities by catalyzing academic and community collaborations that have resulted in linguistically specific and culturally tailored educational products, scientifically rigorous interventions addressed at cancer risk factors, and nurturing new and early stage Asian American cancer investigators. Cancer 2018;124:1527-34. © 2018 American Cancer Society.

Social-cultural, traditional beliefs, and health system barriers of hepatitis B screening among Hmong Americans: A case study

BACKGROUND

The incidence of liver cancer in Hmong Americans is 5 times higher than that of non-Hispanic whites, and there is a low hepatitis B screening rate (24%) among Hmong adults compared with other Asian American populations. The purpose of this study was to examine the Hmong's perceptions on social-cultural determinants, traditional health beliefs, and health care system barriers that influenced community-based hepatitis B screening interventions.

METHODS

A qualitative method was used, integrating a collective case study research design. In-depth interviews were used to collect data from 20 Hmong adults from the greater Sacramento area. A pattern matching analytic technique was used to analyze the data. The main core elements of Culture Care Theory were used to capture the key themes presented by the participants.

RESULTS

Protecting a family's reputation; fear of doctors, medical procedures, and test results; lack of trust in medical doctors and medical care services; and using Hmong herbal medicines and practicing spiritual healing were identified as social-cultural and traditional health belief barriers to obtaining HBV screening. Health care costs, perceived discrimination, lack of transportation, linguistic discordance, and poor quality of care were identified as barriers to accessing high-quality health care services and obtaining hepatitis B screening.

CONCLUSION

Providers, health policy makers, researchers, and community-based organizations will need to work together to develop intervention strategies to address the social-cultural factors, traditional health beliefs, and health care challenges that influence obtaining hepatitis B screening in the Hmong community. Cancer 2018;124:1576-82. © 2018 American Cancer Society.

Systematic Review: Health Promotion and Disease Prevention Among Hmong Adults in the USA

Although disparities in the burden of disease and illness experienced across major racial and ethnic groups in the USA is well known, little is known about subgroups, including the Hmong population. This review sought to determine the current state of health disparities related to health promotion and disease prevention among Hmong adults from 1975 to 2015. Seventy-one descriptive (qualitative, mixed methods, and quantitative) studies were reviewed. Most focused on two areas: (1) health status (mainly breast and cervical cancers) and (2) health-related behaviors. This literature review confirms the existence of health disparities related to health promotion and disease prevention in the Hmong adult population. Effective intervention relies on identifying these disparities. A possible explanation for these disparities is the lack of health data collected on subgroup populations, which include the Hmong adult population. More research and more comprehensive health policies at the organizational level are needed to allow data to be collected on subgroup populations in order to better understand the social determinants that place the Hmong people at risk.

Cancer statistics for Asian Americans, Native Hawaiians, and Pacific Islanders, 2016: Converging incidence in males and females

Cancer is the leading cause of death among Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPIs). In this report, the American Cancer Society presents AANHPI cancer incidence data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data from the National Center for Health Statistics. Among AANHPIs in 2016, there will be an estimated 57,740 new cancer cases and 16,910 cancer deaths. While AANHPIs have 30% to 40% lower incidence and mortality rates than non-Hispanic whites for all cancers combined, risk of stomach and liver cancers is double. The male-to-female incidence rate ratio among AANHPIs declined from 1.43 (95% confidence interval, 1.36-1.49) in 1992 to 1.04 (95% confidence interval, 1.01-1.07) in 2012 because of declining prostate and lung cancer rates in males and increasing breast cancer rates in females. The diversity within the AANHPI population is reflected in the disparate cancer risk by subgroup. For example, the overall incidence rate in Samoan men (526.5 per 100,000) is more than twice that in Asian Indian/Pakistani men (216.8). Variations in cancer rates in AANHPIs are related to differences in behavioral risk factors, use of screening and preventive services, and exposure to cancer-causing infections. Cancer-control strategies include improved use of vaccination and screening; interventions to increase physical activity and reduce excess body weight, tobacco use, and alcohol consumption; and subgroup-level research on burden and risk factors. CA Cancer J Clin 2016;66:182-202. © 2016 American Cancer Society.

mHealth Pilot Study: Text Messaging Intervention to Promote HPV Vaccination

OBJECTIVES

To test the feasibility and efficacy of a culturally-tailored mobile health intervention designed to increase knowledge about, intent to obtain, and receipt of the HPV vaccine.

METHODS

A 7-day text message HPV intervention was developed using a quasi-experimental research design for 30 Korean-American women.

RESULTS

Participants demonstrated significant increases in knowledge of HPV with an intent to get vaccinated within one year, and 30% of participants received the first dose of the HPV vaccine.

CONCLUSIONS

Mobile health technology could be a promising tool in reducing the cancer burden for underserved populations.

Guidelines for conducting rigorous health care psychosocial cross-cultural/language qualitative research

The purpose of this article is to synthesize and chronicle the authors' experiences as four bilingual and bicultural researchers, each experienced in conducting cross-cultural/cross-language qualitative research. Through narrative descriptions of experiences with Latinos, Iranians, and Hmong refugees, the authors discuss their rewards, challenges, and methods of enhancing rigor, trustworthiness, and transparency when conducting cross-cultural/cross-language research. The authors discuss and explore how to effectively manage cross-cultural qualitative data, how to effectively use interpreters and translators, how to identify best methods of transcribing data, and the role of creating strong community relationships. The authors provide guidelines for health care professionals to consider when engaging in cross-cultural qualitative research.

Mobile phone text messaging intervention for cervical cancer screening: changes in knowledge and behavior pre-post intervention

Background

Cervical cancer poses a significant threat to Korean American women, who are reported to have one of the highest cervical cancer mortality rates in the United States. Studies consistently report that Korean American women have the lowest Pap test screening rates across US ethnic groups.

Objective

In response to the need to enhance cervical cancer screening in this vulnerable population, we developed and tested a 7-day mobile phone text message-based cervical cancer Screening (mScreening) intervention designed to promote the receipt of Pap tests by young Korean American women.

Methods

We developed and assessed the acceptability and feasibility of a 1-week mScreening intervention to increase knowledge of cervical cancer screening, intent to receive screening, and the receipt of a Pap test. Fogg’s Behavior Model was the conceptual framework that guided the development of the mScreening intervention. A series of focus groups were conducted to inform the development of the intervention. The messages were individually tailored for each participant and delivered to them for a 7-day period at each participant’s preferred time. A quasi-experimental research design of 30 Korean American women aged 21 to 29 years was utilized with baseline, post (1 week after the completion of mScreening), and follow-up (3 months after the completion of mScreening) testing.

Results

Findings revealed a significant increase in participants’ knowledge of cervical cancer (P<.001) and guidelines for cervical cancer screening (P=.006). A total of 23% (7/30) (95% CI 9.9-42.3) of the mScreening participants received a Pap test; 83% (25/30) of the participants expressed satisfaction with the intervention and 97% (29/30) reported that they would recommend the program to their friends, indicating excellent acceptability and feasibility of the intervention.

Conclusions

This study provides evidence of the effectiveness and feasibility of the mScreening intervention. Mobile technology is a promising tool to increase both knowledge and receipt of cervical cancer screening. Given the widespread usage of mobile phones among young adults, a mobile phone-based health intervention could be a low-cost and effective method of reaching populations with low cervical cancer screening rates, using individually tailored messages that cover broad content areas and overcome restrictions to place and time of delivery.

"We don't talk about it" and other interpersonal influences on Hmong women's breast and cervical cancer screening decisions

Hmong women in the United States have low rates of breast and cervical cancer screening, and the factors that influence screening in this population are not well understood. This qualitative study explored family and clan influences on Hmong women's breast and cervical cancer screening attitudes and behavior. We conducted in-depth interviews with Hmong women and men living in Oregon. Interviews were audio-recorded and transcribed. Transcripts of 83 interviews were analysed using content analysis. We identified four key themes. First, Hmong women make decisions about breast and cervical cancer screening independently. Second, Hmong families do not discuss breast and cervical cancer screening. For some, not talking about breast and cervical cancer screening was seen as a way that family and clan influence attitudes. Third, Hmong families can provide encouragement and support for screening. Although women make their own decisions, about one-half of participants reported that family encouraged or supported them or women in their family to get screened. Fourth, some family members, especially elders, may actively discourage screening. This study contributes to knowledge about potential barriers and facilitators to breast and cervical cancer screening for Hmong women. Findings expand our understanding of clan and male family member's influence over Hmong women's screening behavior.

Increasing hepatitis B screening for hmong adults: results from a randomized controlled community-based study

BACKGROUND

Hepatitis B-linked liver cancer disproportionately affects Hmong Americans. With an incidence rate of 18.9 per 100,000, Hmong Americans experience liver cancer at a rate that is 6 to 7 times more than that of non-Hispanic Whites. Serologic testing for the hepatitis B virus (HBV) is a principal means to prevent liver cancer-related deaths through earlier identification of those at risk.

METHODS

Academic researchers and Hmong leaders collaborated in the design, conduct, and evaluation of a 5-year randomized controlled trial testing a lay health worker (LHW) intervention to promote HBV testing among 260 Hmong adults through in-home education and patient navigation.

RESULTS

Intervention group participants were more likely to report receiving serologic testing for HBV (24% vs. 10%, P = 0.0056) and showed a greater mean increase in knowledge score (1.3 vs. 0.3 points, P = 0.0003) than control group participants. Multivariable modeling indicated that self-reported test receipt was associated with intervention group assignment [OR 3.5; 95% confidence interval (CI) 1.3-9.2], improvement in knowledge score (OR 1.3 per point; 95% CI 1.02-1.7), female gender (OR 5.3; 95% CI 1.7-16.6), and having seen a doctor in the past year at baseline (OR 4.8; 95% CI 1.3-17.6). The most often cited reason for testing was a doctor's recommendation.

CONCLUSIONS

LHWs were effective in bringing about HBV screening. Doctor visits and adherence to doctors' recommendations were pivotal. Participation of health care providers is essential to increase HBV testing.

IMPACT

LHWs can significantly increase HBV screening rates for Hmong but their doctors' recommendation is highly influential and should be pursued.

Increasing hepatitis B screening for hmong adults: results from a randomized controlled community-based study

BACKGROUND

Hepatitis B-linked liver cancer disproportionately affects Hmong Americans. With an incidence rate of 18.9 per 100,000, Hmong Americans experience liver cancer at a rate that is 6 to 7 times more than that of non-Hispanic Whites. Serologic testing for the hepatitis B virus (HBV) is a principal means to prevent liver cancer-related deaths through earlier identification of those at risk.

METHODS

Academic researchers and Hmong leaders collaborated in the design, conduct, and evaluation of a 5-year randomized controlled trial testing a lay health worker (LHW) intervention to promote HBV testing among 260 Hmong adults through in-home education and patient navigation.

RESULTS

Intervention group participants were more likely to report receiving serologic testing for HBV (24% vs. 10%, P = 0.0056) and showed a greater mean increase in knowledge score (1.3 vs. 0.3 points, P = 0.0003) than control group participants. Multivariable modeling indicated that self-reported test receipt was associated with intervention group assignment [OR 3.5; 95% confidence interval (CI) 1.3-9.2], improvement in knowledge score (OR 1.3 per point; 95% CI 1.02-1.7), female gender (OR 5.3; 95% CI 1.7-16.6), and having seen a doctor in the past year at baseline (OR 4.8; 95% CI 1.3-17.6). The most often cited reason for testing was a doctor's recommendation.

CONCLUSIONS

LHWs were effective in bringing about HBV screening. Doctor visits and adherence to doctors' recommendations were pivotal. Participation of health care providers is essential to increase HBV testing.

IMPACT

LHWs can significantly increase HBV screening rates for Hmong but their doctors' recommendation is highly influential and should be pursued.

Risk of localized and advanced prostate cancer among immigrants versus native-born Swedish men: a nation-wide population-based study

PURPOSE

Prostate cancer (PCa) incidence and prognosis vary geographically. We examined possible differences in PCa risk by clinical risk category between native-born and immigrant populations in Sweden. Our hypothesis was that lower PSA-testing uptake among foreign-born men would result in lower rates of localized disease, and similar or higher risk of metastatic disease.

METHODS

Using the Prostate Cancer database Sweden, we identified 117,328 men with PCa diagnosed from 1991 to 2008, of which 8,332 were foreign born. For each case, 5 cancer-free matched controls were randomly selected from the population register. Conditional logistic regression was used to compare low risk, intermediate risk, high risk, regionally metastatic, and distant metastatic PCa based upon region of origin.

RESULTS

Across all risk categories, immigrants had significantly lower PCa risk than native-born Swedish men, except North Americans and Northern Europeans. The lowest PCa risk was observed in men from the Middle East, Southern Europe, and Asia. Multivariable adjustment for socioeconomic factors and comorbidities did not materially change risk estimates. Older age at immigration and more recent arrival in Sweden were associated with lower PCa risk. Non-native men were less likely to be diagnosed with PCa through PSA testing during a health checkup.

CONCLUSIONS

The risk for all stages of PCa was lower among first-generation immigrants to Sweden compared with native-born men. Older age at immigration and more recent immigration were associated with particularly low risks. Patterns of PSA testing appeared to only partly explain the differences in PCa risk, since immigrant men also had a lower risk of metastatic disease.

Racial differences in colorectal cancer incidence and mortality in the Women's Health Initiative

BACKGROUND

Colorectal cancer (CRC) incidence and mortality rates are higher in African-Americans as compared with other racial/ethnic groups. The women's health initiative (WHI) study sample was used to determine whether differences in CRC risk factors explain racial/ethnic differences in incidence and mortality.

METHODS

The WHI is a longitudinal study of postmenopausal women recruited from 40 centers. Baseline questionnaires were used to collect sociodemographic and health status information. All CRC diagnoses were centrally adjudicated. Cox regression models were used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for invasive CRC by race/ethnicity.

RESULTS

The study sample included 131,481 (83.7%) White, 14,323 (9.1%) African-American, 6,362 (4.1%) Hispanic, 694 (0.4%) Native American and 4,148 (2.6%) Asian/Pacific Islanders. After a mean follow-up of 10.8 years (SD 2.9), CRC incidence was the highest in African-Americans (annualized rate = 0.14%), followed by Whites and Native Americans (0.12% each), Asian/Pacific Islanders (0.10%), and Hispanics (0.08%). After adjustment for age and trial assignment, Hispanics had a lower risk compared with Whites, HR 0.73 (95% CI: 0.54-0.97) (P = 0.03), and African-Americans had a marginally greater risk, HR 1.16 (95% CI: 0.99-1.34), P = 0.06. Multivariable adjustment attenuated the difference in incidence between African-Americans and Whites (HR 0.99, 95% CI: 0.82-1.20), while strengthening the lower HR for Hispanics (HR 0.68, 95% CI: 0.48-0.97).

CONCLUSIONS

African-American/White differences in CRC risk are likely due to sociodemographic/cultural factors other than race.

IMPACT

A number of modifiable exposures could be a focus for reducing CRC risk in African-Americans.

Lessons learned from the application of a Vietnamese surname list for survey research

Surname lists are increasingly being used to identify Asian study participants. Two Vietnamese surname lists have previously been published: the Vietnamese Community Health Promotion Program (VCHPP) list and the Lauderdale list. This report provides findings from a descriptive analysis of the performance of these lists in identifying Vietnamese. To identify participants for a survey of Vietnamese women, a surname list (that included names that appear on the VCHPP list and/or Lauderdale list) was applied to the Seattle telephone book. We analyzed surname data for all addresses in the survey sample, as well as survey respondents. The VCHPP list identified 4,283 potentially Vietnamese households, and 79% of the households with established ethnicity were Vietnamese; and the Lauderdale list identified 4,068 potentially Vietnamese households, and 80% of the households with established ethnicity were Vietnamese. However, the proportions of contacted households that were Vietnamese varied significantly among commonly occurring surnames. The characteristics of women with surnames on the VCHPP and Lauderdale lists were equivalent. The two lists performed equally well in identifying Vietnamese households. Researchers might consider using different combinations of Vietnamese surnames, depending on whether accuracy or high population coverage is the more important consideration.

Interventions that increase use of Pap tests among ethnic minority women: a meta-analysis

OBJECTIVE

Although a variety of intervention methods have been used to promote Pap test screening among ethnic minority women in the US, the effectiveness of such interventions is unclear. We performed a meta-analysis to examine the overall effectiveness of these interventions in increasing Pap test use by ethnic minority women in the US.

METHODS

A search of databases (MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Science Citation Index-Expanded) and review articles for articles published between 1984 and April 2009 identified 18 randomized and non-randomized controlled trials. The primary study outcome was the difference in the proportion of Pap tests between the treatment and comparison groups.

RESULTS

The pooled mean weighted effect size (d) for the 18 studies was 0.158 (95% confidence interval [CI]=0.100, 0.215), indicating that the interventions were effective in improving Pap test use among ethnic minority women. Among the intervention types, access enhancement yielded the largest effect size (0.253 [95% CI=0.110, 0.397]), followed by community education (0.167 [95% CI=0.057, 0.278]) and individual counseling or letters (0.132 [95% CI=0.069, 0.195]). Combined intervention effects were significant for studies targeting Asian (0.177 [95% CI=0.098, 0.256]) and African American women (0.146 [95% CI=0.028, 0.265]), but not Hispanic women (0.116 [95% CI=-0.008, 0.240]).

CONCLUSIONS

Pap test use among ethnic minority women is most likely to increase when access-enhancing strategies are combined. Further research is needed to determine whether more tightly controlled trials of such interventions might reveal an improved rate of cervical cancer screening in Hispanic women as well.

Prevalence of hepatitis B virus (HBV) infection among Hmong immigrants in the San Joaquin Valley

Chronic hepatitis B infection (HBV) is the major cause of primary liver cancer worldwide and Asians are disproportionately affected. The prevalence of HBV among most Asian American groups has been well documented, except in Hmong immigrants in the United States. The aim of this study was to determine the prevalence of HBV among Hmong immigrants in the San Joaquin Valley of California. A convenient sample of 534 Hmong age ≥18 years was recruited at various locations throughout Fresno County. Blood samples from study participants were collected and tested for hepatitis B surface antigen (HBsAg) by enzyme-immunoassay. Two hundred and eighty-nine females and 245 males of Hmong descent (mean age, 43.93) were screened. Eighty-nine (41 males and 48 females) were positive for HBsAg, which accounts for a prevalence of 16.7% (95% C.I. 13.5–19.9). The majorities of HBsAg positive patients were ≥40 years (64.2%), married (66.7%), born in Laos (87.3%), and had lived in the United States ≥20 years (62.5%). Only 37.5% of the participants reported having a primary care physician. Our study revealed that approximately one out of every six Hmong immigrants screened was infected with HBV. Based on our findings, more than one-third of these infected patients have no primary care physician to provide further treatment, surveillance for liver cancer, or vaccination of their families. This supports the Institute of Medicine’s recent recommendations to the Center for Disease Control to engage in a national Hepatitis B surveillance system.

Seeking to bridge two cultures: the Wisconsin Hmong cancer experience

Compared to white non-Hispanics, Hmong report higher incidence rates of certain cancers and present at an advanced stage. Using a community-based participatory research approach, Hmong leaders partnered with academic researchers to assess the Wisconsin Hmong population's readiness to address cancer. Using the Colorado Tri-Ethnic Center's Community Readiness Assessment, face-to-face interviews were conducted with eight Hmong leaders. The stage of readiness to address cancer was "Vague Awareness". Six thematic areas provided insight into this stage and recommendations for effective intervention. Results emphasize the need for a bridge between Hmong and mainstream communities to provide basic, culturally appropriate education on the US healthcare system and cancer.

Persistent disparities in pap test use: assessments and predictions for Asian women in the U.S., 1982-2010

Disparities in cancer screening among U.S. women are well documented. However, little is known about Pap test use by Asian women living in the U.S. Data for women, ages 18 and older, living in the U.S. were obtained from National Health Interview Survey (NHIS) files from 1982 to 2005. Outcomes were ever having a Pap test and having a Pap test within the preceding 3 years. Pap test prevalence trends were estimated by race and ethnicity and for Asian subgroups. Fractional logit models were used to predict Pap test use in 2010. Although the rate of having a Pap test within the preceding 3 years increased slightly from 1982 to 2005 for all U.S. women, Asian women continue to have the lowest rate. Pap test use also varied within Asian subpopulations living in the U.S. None of the races and ethnicities are predicted to reach the Pap test targets of Healthy People 2010. To reduce or eliminate continuing disparities in Pap test use requires targeted policy interventions.

Disparities in hepatocellular carcinoma survival among Californians of Asian ancestry, 1988 to 2007

BACKGROUND

Hepatocellular carcinoma (HCC) represents a significant health disparity affecting Asian Americans, a population comprised of distinct ethnic groups. The purpose of this article is to analyze Californians of Asian ancestry with HCC with respect to socioeconomic status, demographic factors, stage of disease, treatment received, and survival.

METHODS

To investigate ethnic differences in survival, we analyzed ethnically disaggregated data from 6,068 Californians of Asian ancestry with HCC diagnosed in 1988 to 2007 and reported to the California Cancer Registry.

RESULTS

Compared with the average of all ethnic groups, cause-specific mortality was significantly higher among Laotian/Hmong [hazard ratio, 2.08; 95% confidence interval (95% CI), 1.78-2.44] and Cambodian patients (hazard ratio, 1.26; 95% CI, 1.06-1.51), groups with higher proportions of their populations at low levels of socioeconomic status; in addition, Laotian/Hmong patients disproportionately presented at later stages of disease, with only 3% receiving local surgical treatment, resection, or liver transplantation. After adjustment for time of diagnosis, age at diagnosis, gender, geographic region, stage at diagnosis, type of surgery, and socioeconomic status, survival disparities remained for both groups (Laotian/Hmong hazard ratio, 1.51; 95% CI, 1.28-1.79; Cambodian hazard ratio, 1.24; 95% CI, 1.03-1.48).

CONCLUSIONS

Our hypothesis that survival outcomes would differ by ethnicity was verified.

IMPACT

Research is needed not only to develop more effective treatments for HCC but also to develop community-based interventions to recruit Asian Americans, particularly Laotian/Hmong and Cambodians, for hepatitis B screening and into medical management to prevent or detect this tumor at an early stage.

Factors associated with pap testing among Hmong women

This paper reports the baseline data on the proportion of Hmong women (n=402), ages 18-65, in Sacramento, California who reported that they had a Pap test for the early detection of cervical cancer. We assessed the association between sociodemographic characteristics and Pap test receipt using chi-squared and multiple logistic regression analyses. Only 74% had ever had a Pap test, with 61% tested in the previous three years, compared with 91% and 86%, respectively, of California women overall. Women were more likely to have had a recent Pap test if they were age 21-30 (OR=3.0 vs. age 51-65, 95% CI 1.4-6.7) or 31-40 (OR=3.0, 95% CI 1.4-6.4), and less likely if they were single (OR=0.4 vs. married/partnered, 95% CI 0.2-1.0) or born in the U.S. (OR=0.3 vs. <10 years in U.S., 95% CI 0.1-0.8).

Barriers to cancer screening in Hmong Americans: the influence of health care accessibility, culture, and cancer literacy

Hmong Americans face high cancer mortality rates even in comparison to their Asian American counterparts, and report low utilization of cancer screenings. To date, no study has been conducted on the cultural barriers this population faces in undergoing cancer screenings. A systematic review of the literature was conducted to examine the existing knowledge regarding the barriers to cancer screening for Hmong Americans. Potential barriers were identified from this examination to include: health access factors (type of health insurance, ethnicity of provider, low English proficiency, and years spent in the U.S.); cultural factors (belief in the spiritual etiology of diseases, patriarchal values, modesty, and mistrust of the western medical system); and cancer literacy factors (cancer and prevention illiteracy). Based on this review, potential cultural and ethnic group-specific prevention strategies and cancer health policies are discussed to address these barriers and enhance screening behavior among the Hmong.

Cervical cancer incidence, mortality, and survival among Asian subgroups in California, 1990-2004

BACKGROUND

Aggregated cancer statistics for Asians mask important differences in cancer burden among Asian subgroups. The purpose of this study was to describe the relative patterns of cervical cancer incidence, mortality, and survival among Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese women in California, using data from the California Cancer Registry.

METHODS

All cervical cancer cases diagnosed among the 6 subgroups and non-Hispanic whites (NHW) from 1990 to 2004 were identified and used to calculate incidence and mortality rates and trends. The Kaplan-Meier method was used to calculate 5- and 10-year survival probabilities by subgroup, and Cox proportional hazards methodology was used to calculate survival differences adjusted for race and ethnicity, age, stage at diagnosis, socioeconomic status, and treatment factors.

RESULTS

Vietnamese and Korean women experienced greater cervical cancer incidence and mortality than NHW women, whereas rates among Chinese, Japanese, and South Asians were comparable or lower. Five-year unadjusted survival probabilities were greatest for South Asians (86%) and Koreans (86%), followed by Vietnamese (82%), Chinese (79%), and Filipinos (79%), as compared with NHW (78%) and Japanese (72%). The adjusted risk of cervical cancer death was significantly lower for South Asians, Koreans, Vietnamese, and Filipinos than for NHW women, but not for Chinese and Japanese.

CONCLUSIONS

Cervical cancer incidence rates vary substantially across the major Asian subgroups. Despite higher incidence and mortality rates compared with NHW women, Vietnamese, Koreans, and Filipinos have better survival outcomes. Further studies are needed to examine the factors behind these survival differences.

Thyroid cancer in the Middle Eastern population of California

OBJECTIVE

To describe and compare the epidemiology of thyroid cancer in the rapidly growing Middle Eastern (ME) population and the non-Hispanic, non-Middle Eastern White (NHNMW) residents of California. Population with ME heritage that is officially not recognized as a distinct ethnicity has rarely been studied in the past.

METHODS

ME cases in the California cancer registry files for 1988-2004 were identified by surname recognition. ME population was estimated by ancestry from census data.

RESULTS

Thyroid cancer in ME group, 869 cases and 56 deaths were compared with 19,182 cases and 1,327 deaths in the NHNMW population. Age-adjusted rate ratio (RR) for incidence was 1.5 (95% CI 1.3-1.7) in men and 1.5 (95% CI 1.4-1.7) in women. RR for mortality was 1.4 (95% CI 0.9-2.4) in men and 2.3 (95% CI 1.4-3.9) in women. Papillary tumors comprised over 80% of all cases and their pattern correlated with the rapid increase in thyroid cancer in recent years. Five-year observed survival in ME men was significantly higher than in NHNMW men, but similar in women.

CONCLUSIONS

Eighty-five percent of ME cases identified in this study were born in the Middle East. The higher incidence of thyroid cancer in this immigrant population may largely reflect a combination of sequels of radiation treatment for fungal diseases of the scalp that was common in the area in early 1950s, benign proliferative thyroid disease that is common in the area due to dietary iodine imbalance, and possibly genetic predisposition.

Construction and validation of a list of common Middle Eastern surnames for epidemiological research

PURPOSE

Middle Eastern (ME) population is rapidly growing in the US but cannot be easily identified in cancer registry or other databases for epidemiological research. The purpose of this study was to develop a list of common Middle Eastern surnames and validate it by linking with a cancer registry incidence files.

METHODS

Surnames and place of birth in the Middle East were obtained from various sources. After exclusion of the non-specific entries, the final combined list included 49,610 surnames and was matched with the California Cancer Registry incidence file for 1988-2003.

RESULTS

Overall, 1.4% of all registered cases were positively identified as ME that is similar to the proportion of ME population in California. Two third of the identified cases had known place of birth in the Middle East and of those, 70% were non-Arabs. The sensitivity of the list in detecting ME birth in men and women are 91% and 86%, respectively. The positive predictive values for men and women are 72% and 65%. The specificity and negative predictive values are universally over 99%.

CONCLUSION

The high accuracy reported for this Middle Eastern surname list (MESL) makes it a valuable tool for epidemiological studies of this ethnic population.

Asian American Network for Cancer Awareness, Research, and Training's legacy. The first 5 years

The Asian American Network for Cancer Awareness, Research, and Training (AANCART) is the first special populations network for Asian Americans on a national basis and includes collaborating organizations from Boston, New York, Houston, Seattle, San Francisco, Los Angeles, Hawaii, and Sacramento (where it is headquartered at the University of California, Davis). NCI funding of AANCART in 2000 brought together investigators and leaders from 9 cities across 6 states to establish an infrastructure for addressing cancer awareness, research, and training. Since 2000, AANCART has conducted needs assessments, held community awareness activities and trainings, trained trainees, sponsored National Asian American Cancer Control Academies, and produced presentations, publications, and grants. All specific aims have been attained, including the establishment of an infrastructure to promote Asian American cancer awareness, research, and training in 4 targeted regions; the establishment of partnerships to promote accrual to clinical trials, training, and pilot studies; and the formulation and successful implementation of grant-funded research to reduce the cancer burden among Asian Americans. AANCART's first 5 years have increased cancer awareness, trained special populations scientists, and advanced the field of Asian American cancer control research. Cancer 2006. (c) 2006 American Cancer Society.

Cervical cancer incidence in a prevaccine era in the United States, 1998-2002

OBJECTIVE

To report the incidence of cervical cancer by geography, race or ethnicity, and histology.

METHODS

We examined combined data from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results Program covering 87% of the U.S. population. We calculated the age-adjusted incidence of cervical cancer by age, race or ethnicity, histology, and stage by region or state.

RESULTS

Rates of invasive cancer per 100,000 females declined from 10.2 in 1998 to 8.5 in 2002. Incidence rates by state ranged from 6.6 to 12.3 per 100,000. Rates were especially high among Hispanic women aged 40 years or older (26.5 or more) and African-American women aged older than 50 years (23.5 or more). Rates of squamous cell carcinoma were significantly higher among African-American and Hispanic women than among their white counterparts. In contrast, rates of adenocarcinoma (18% of all cases) were significantly lower among African-American women than in white women (rate ratio 0.88, P<.05). Rates of adenocarcinoma were significantly higher among Hispanic women than among non-Hispanics (rate ratio 1.71, P<.05). Although no regional differences were noted for adenocarcinoma, rates of squamous cell carcinoma were higher in the South than in other regions.

CONCLUSION

Despite intense screening in the past decade, higher rates of cervical cancer persist among women in the South and women who are African American or Hispanic. This information could guide more focused interventions to increase access to screening with cervical cytology as well as vaccination against human papillomavirus.

LEVEL OF EVIDENCE

III.

Asian subgroups and cancer incidence and mortality rates in California

The objective of this study was to characterize better the cancer burden among Asian subgroups in California. Nearly 3.7 million Asians reside in California, and no other state has as many Asians. Cancer statistics for Asians often are combined with statistics for Pacific Islanders, and rates for subgroups are not often examined, because most states do not have a large enough population. Asians are affected disproportionately by certain cancers, such as stomach and liver cancers. The California Cancer Registry, a population-based cancer registry, has collected data, including race/ethnicity data, since 1988. The 5-year, average, annual, age-adjusted cancer incidence and mortality rates from 1997 through 2001 were calculated for 5 Asian subgroups: Chinese, Filipino, Japanese, Korean, and Vietnamese. Cancer incidence and mortality varied greatly. Incidence rates for all sites combined among males varied from a low of 318.6 per 100,000 for Chinese to a high of 366.0 per 100,000 among Japanese. For females, rates ranged from 236.6 per 100,000 among Koreans to 302.4 per 100,000 among Japanese. Mortality rates also varied by Asian subgroup. Presenting one statistic for Asian/Pacific Islanders did not provide an accurate depiction of the cancer burden among the different Asian subgroups. Acculturation will continue to affect the patterns of cancer incidence among Asian subgroups in California.