Primary liver cancer incidence among American Indians and Alaska Natives, US, 1999-2004

Assessment of Racial Misclassification Among American Indian and Alaska Native Identity in Cancer Surveillance Data in the United States and Considerations for Oral Health: A Systematic Review

Introduction

Misclassification of American Indian and Alaska Native (AI/AN) peoples exists across various databases in research and clinical practice. Oral health is associated with cancer incidence and survival; however, misclassification adds another layer of complexity to understanding the impact of poor oral health. The objective of this literature review was to systematically evaluate and analyze publications focused on racial misclassification of AI/AN racial identities among cancer surveillance data.

Methods

The PRISMA Statement and the CONSIDER Statement were used for this systematic literature review. Studies involving the racial misclassification of AI/AN identity among cancer surveillance data were screened for eligibility. Data were analyzed in terms of the discussion of racial misclassification, methods to reduce this error, and the reporting of research involving Indigenous peoples.

Results

A total of 66 articles were included with publication years ranging from 1972 to 2022. A total of 55 (83%) of the 66 articles discussed racial misclassification. The most common method of addressing racial misclassification among these articles was linkage with the Indian Health Service or tribal clinic records (45 articles or 82%). The average number of CONSIDER checklist domains was three, with a range of zero to eight domains included. The domain most often identified was Prioritization (60), followed by Governance (47), Methodologies (31), Dissemination (27), Relationships (22), Participation (9), Capacity (9), and Analysis and Findings (8).

Conclusion

To ensure equitable representation of AI/AN communities, and thwart further oppression of minorities, specifically AI/AN peoples, is through accurate data collection and reporting processes.

Misracialization of Indigenous people in population health and mortality studies: a scoping review to establish promising practices

Indigenous people are often misracialized as other racial or ethnic identities in population health research. This misclassification leads to underestimation of Indigenous-specific mortality and health metrics, and subsequently, inadequate resource allocation. In recognition of this problem, investigators around the world have devised analytic methods to address racial misclassification of Indigenous people. We carried out a scoping review based on searches in PubMed, Web of Science, and the Native Health Database for empirical studies published after 2000 that include Indigenous-specific estimates of health or mortality and that take analytic steps to rectify racial misclassification of Indigenous people. We then considered the weaknesses and strengths of implemented analytic approaches, with a focus on methods used in the US context. To do this, we extracted information from 97 articles and compared the analytic approaches used. The most common approach to address Indigenous misclassification is to use data linkage; other methods include geographic restriction to areas where misclassification is less common, exclusion of some subgroups, imputation, aggregation, and electronic health record abstraction. We identified 4 primary limitations of these approaches: (1) combining data sources that use inconsistent processes and/or sources of race and ethnicity information; (2) conflating race, ethnicity, and nationality; (3) applying insufficient algorithms to bridge, impute, or link race and ethnicity information; and (4) assuming the hyperlocality of Indigenous people. Although there is no perfect solution to the issue of Indigenous misclassification in population-based studies, a review of this literature provided information on promising practices to consider.

Advancing Liver Cancer Prevention for American Indian Populations in Arizona: An Integrative Review

Liver cancer is a highly fatal condition disproportionately impacting American Indian populations. A thorough understanding of the existing literature is needed to inform region-specific liver cancer prevention efforts for American Indian people. This integrative review explores extant literature relevant to liver cancer in American Indian populations in Arizona and identifies factors of structural inequality affecting these groups. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines informed the methodology, and a literature search was conducted in PubMed, EMBASE, CINAHL, and PsycInfo for articles including Arizona American Indian adults and liver disease outcomes. Seven articles met the inclusion criteria in the final review. Five of the studies used an observational study design with secondary analysis. One article used a quasiexperimental approach, and another employed a community-engagement method resulting in policy change. The results revealed a lack of empirical evidence on liver cancer prevention, treatment, and health interventions for American Indian populations in Arizona. Research is needed to evaluate the high rates of liver disease and cancer to inform culturally relevant interventions for liver cancer prevention. Community-engaged research that addresses structural inequality is a promising approach to improve inequities in liver cancer for American Indian people.

Racial and Sex Disparities in Hepatocellular Carcinoma in the USA

PURPOSE OF REVIEW

In this review, we aim to provide a summary of the current literature on race and gender disparities in hepatocellular carcinoma (HCC) incidence, stage at diagnosis, treatment and prognosis in the United States.

RECENT FINDINGS

HCC incidence rates are rising in the U.S. in all racial/ethnic groups except for Asian/Pacific Islanders, with disproportionate rises and the highest rates among Hispanics compared to Blacks and non-Hispanic whites. There are striking sex disparities in HCC incidence and mortality; however, with the shifting epidemiology of HCC risk factors in the U.S, there is recent evidence that HCC is trending towards less male predominance, particularly among younger birth cohorts. Despite significant advances in HCC treatment over the past decade, disparities in HCC surveillance and treatment receipt persist among racial and ethnic minorities and the socioeconomically disadvantaged. Black patients continue to experience worse survival outcomes than non-Black patients with HCC.

SUMMARY

There are significant racial and gender disparities in HCC incidence, treatment, and mortality in the U.S. Though these disparities are well-documented, data are still limited on the specific determinants driving disparities in HCC. To achieve health equity for all patients with HCC, we must advance beyond simply reporting on disparities and begin implementing targeted interventions to eliminate disparities.

Incidence of primary liver cancer in American Indians and Alaska Natives, US, 1999-2009

PURPOSE

To evaluate liver cancer incidence rates and risk factor correlations in non-Hispanic AI/AN populations for the years 1999-2009.

METHODS

We linked data from 51 central cancer registries with the Indian Health Service patient registration databases to improve identification of the AI/AN population. Analyses were restricted to non-Hispanic persons living in Contract Health Service Delivery Area counties. We compared age-adjusted liver cancer incidence rates (per 100,000) for AI/AN to white populations using rate ratios. Annual percent changes (APCs) and trends were estimated using joinpoint regression analyses. We evaluated correlations between regional liver cancer incidence rates and risk factors using Pearson correlation coefficients.

RESULTS

AI/AN persons had higher liver cancer incidence rates than whites overall (11.5 versus 4.8, RR = 2.4, 95% CI 2.3-2.6). Rate ratios ranged from 1.6 (Southwest) to 3.4 (Northern Plains and Alaska). We observed an increasing trend among AI/AN persons (APC 1999-2009 = 5%). Rates of distant disease were higher in the AI/AN versus white population for all regions except Alaska. Alcohol use (r = 0.84) and obesity (r = 0.79) were correlated with liver cancer incidence by region.

CONCLUSIONS

Findings highlight disparities in liver cancer incidence between AI/AN and white populations and emphasize opportunities to decrease liver cancer risk factor prevalence.

Racial/ethnic disparities in hepatocellular carcinoma treatment and survival in California, 1988-2012

AIM

To describe racial/ethnic differences in treatment and survival among liver cancer patients in a population-based cancer registry.

METHODS

Invasive cases of primary hepatocellular carcinoma, n = 33270, diagnosed between January 1, 1988-December 31, 2012 and reported to the California Cancer Registry were analyzed by race/ethnicity, age, gender, geographical region, socio-economic status, time period of diagnosis, stage, surgical treatment, and survival. Patients were classified into 15 racial/ethnic groups: non-Hispanic White (White, n = 12710), Hispanic (n = 8500), Chinese (n = 2723), non-Hispanic Black (Black, n = 2609), Vietnamese (n = 2063), Filipino (n = 1479), Korean (n = 1099), Japanese (n = 658), American Indian/Alaskan Native (AIAN, n = 281), Laotian/Hmong (n = 244), Cambodian (n = 233), South Asian (n = 190), Hawai`ian/Pacific Islander (n = 172), Thai (n = 95), and Other Asian (n = 214). The main outcome measures were receipt of surgical treatment, and cause-specific and all-cause mortality.

RESULTS

After adjustment for socio-demographic characteristics, time period, and stage of disease, compared to Whites, Laotian/Hmong [odds ratio (OR) = 0.30, 95%CI: 0.17-0.53], Cambodian (OR = 0.65, 95%CI: 0.45-0.96), AIAN (OR = 0.66, 95%CI: 0.46-0.93), Black (OR = 0.76, 95%CI: 0.67-0.86), and Hispanic (OR = 0.78, 95%CI: 0.72-0.84) patients were less likely, whereas Chinese (OR = 1.58, 95%CI: 1.42-1.77), Koreans (OR = 1.45, 95%CI: 1.24-1.70), Japanese (OR = 1.41, 95%CI: 1.15-1.72), and Vietnamese (OR = 1.26, 95%CI: 1.12-1.42) were more likely to receive surgical treatment. After adjustment for the same covariates and treatment, cause-specific mortality was higher for Laotian/Hmong [(hazard ratio (HR) = 1.50, 95%CI: 1.29-1.73)], Cambodians (HR = 1.35, 95%CI: 1.16-1.58), and Blacks (HR = 1.07, 95%CI: 1.01-1.13), and lower for Chinese (HR = 0.82, 95%CI: 0.77-0.86), Filipinos (HR = 0.84, 95%CI: 0.78-0.90), Vietnamese (HR = 0.85, 95%CI: 0.80-0.90), Koreans (HR = 0.90, 95%CI: 0.83-0.97), and Hispanics (HR = 0.91, 95%CI: 0.88-0.94); results were similar for all-cause mortality.

CONCLUSION

Disaggregated data revealed substantial racial/ethnic differences in liver cancer treatment and survival, demonstrating the need for development of targeted interventions to mitigate disparities.

Racial disparities in treatment and survival of hepatocellular carcinoma in native Americans and Hispanics

BACKGROUND

We investigated if there were any differences in disease presentation and survival between the 3 major ethnicities in New Mexico; non-Hispanic whites (NHW), native Americans (NA), and Hispanics (H).

METHODS

A retrospective analysis of patients with hepatocellular carcinoma treated at our institution between 2000 and 2014 was performed. Overall survival was analyzed using the Kaplan-Meier and Cox regression models.

RESULTS

We identified 326 patients; 106 (32.5%) NHW, 183 (56.1%) H, and 37 (11.4%) NA. No difference in disease stage, resectability, rate of offering surgery, or chemotherapy was found. Advanced cirrhosis was more common in H and NA than NHW (P = .01). NA had a higher incidence of nonviral hepatocellular carcinoma (P = .0009). NHW were more likely to receive transarterial chemoembolization/radiofrequency than NA or H (P = .04). Median survivals for NA, NHW, H were 24, 14, and 11 months, respectively, (P = .01).

CONCLUSIONS

Although there was no difference in disease stage or resectability, NA and H had more advanced cirrhosis and were less likely to undergo transarterial chemoembolization and/or radiofrequency than NHW. NA had the best survival, whereas H had the worst survival.

Combination of individualized local control and target-specific agent to improve unresectable liver cancer managements: a matched case-control study

Management of late-stage hepatocellular carcinoma is difficult. A direct comparison of clinical data is needed in order to demonstrate the survival benefits of different therapies. We directly compared various therapies in a retrospective matched case-control study. A total of 79 patients with unresectable tumors greater than 10 cm in size were included in the study between 2008 and 2012. Thirty-five patients were treated with transarterial chemoembolization for local control, 20 were treated with sorafenib systemic chemotherapy, and 24 received combination treatment. The total follow-up time after initial therapy was 4.5 years. Survival time after treatment was significantly longer in the combination therapy group (P < 0.0001). The median survival times for combination, local control, and systemic chemotherapy were 15 (12-21), 10 (9-13), and 3.5 (2.5-9.0) months (95 % confidence interval), respectively. The hazard ratios for local control and systemic chemotherapy were 1.985 and 5.102, respectively, with combination treatment as the reference. There was no observed difference in combination therapy from the side effects of the individual therapies. In conclusion, the limited availability of therapeutic options for late-stage liver cancer necessitates reliance on multidisciplinary personalized medicine approaches with target-specific medications to increase survival time. Combining individualized local control therapy and drugs that target specific disease markers provides more benefits to patients.

Mortality caused by chronic liver disease among American Indians and Alaska Natives in the United States, 1999-2009

OBJECTIVES

We compared chronic liver disease (CLD) mortality from 1999 to 2009 between American Indians and Alaska Natives (AI/ANs) and Whites in the United States after improving CLD case ascertainment and AI/AN race classification.

METHODS

We defined CLD deaths and causes by comprehensive death certificate-based diagnostic codes. To improve race classification, we linked US mortality data to Indian Health Service enrollment records, and we restricted analyses to Contract Health Service Delivery Areas and to non-Hispanic populations. We calculated CLD death rates (per 100,000) in 6 geographic regions. We then described trends using linear modeling.

RESULTS

CLD mortality increased from 1999 to 2009 in AI/AN persons and Whites. Overall, the CLD death rate ratio (RR) of AI/AN individuals to Whites was 3.7 and varied by region. The RR was higher in women (4.7), those aged 25 to 44 years (7.4), persons residing in the Northern Plains (6.4), and persons dying of cirrhosis (4.0) versus hepatocellular carcinoma (2.5), particularly those aged 25 to 44 years (7.7).

CONCLUSIONS

AI/AN persons had greater CLD mortality, particularly from premature cirrhosis, than Whites, with variable mortality by region. Comprehensive prevention and care strategies are urgently needed to stem the CLD epidemic among AI/AN individuals.

Disparities in cancer mortality and incidence among American Indians and Alaska Natives in the United States

OBJECTIVES

We used improved data on American Indian and Alaska Native (AI/AN) ancestry to provide an updated and comprehensive description of cancer mortality and incidence among AI/AN populations from 1990 to 2009.

METHODS

We linked the National Death Index and central cancer registry records independently to the Indian Health Service (IHS) patient registration database to improve identification of AI/AN persons in cancer mortality and incidence data, respectively. Analyses were restricted to non-Hispanic persons residing in Contract Health Service Delivery Area counties in 6 geographic regions of the United States. We compared age-adjusted mortality and incidence rates for AI/AN populations with White populations using rate ratios and mortality-to-incidence ratios. Trends were described using joinpoint analysis.

RESULTS

Cancer mortality and incidence rates for AI/AN persons compared with Whites varied by region and type of cancer. Trends in death rates showed that greater progress in cancer control was achieved for White populations compared with AI/AN populations over the last 2 decades.

CONCLUSIONS

Spatial variations in mortality and incidence by type of cancer demonstrated both persistent and emerging challenges for cancer control in AI/AN populations.

Linking cancer registry and hospital discharge data for treatment surveillance

Cancer registry data often lack complete chemotherapy and radiation therapy information. To conduct treatment disparity surveillance, we linked 2005–2009 Nebraska Cancer Registry data with Nebraska hospital discharge data. Due to the high quality of both datasets and the proposed linkage procedure, we had a linkage rate of 97 percent. We demonstrate the utilization of the linked dataset in case finding, treatment update, and treatment surveillance. The results show that the linked dataset is likely to identify up to 5 percent of potential missed cases. We investigated the use of radiation therapy in treating colorectal and breast cancers as case-finding examples. The linked dataset found 12 percent and 14 percent more treatment cases for colorectal and breast cancer patients, respectively.

Multiple target-specific molecular imaging agents detect liver cancer in a preclinical model

Liver cancer is the fifth most common cause of cancer deaths worldwide. Noninvasive diagnosis is difficult and the disease heterogeneity reduces the accuracy of pathological assays. Improvement in diagnostic imaging of specific molecular disease markers has provided hope for accurate and early noninvasive detection of liver cancer. However, all current imaging technologies, including ultrasonography, computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging, are not specific targets for detection of liver cancer. The aim of this study was to test the feasibility of injecting a cocktail of specific molecular imaging agents to noninvasively image liver cancer. The target-specific cocktail contained agents for imaging the neovasculature (RGD peptide), matrix metalloproteinase (MMP), and glucose transport (¹⁸F-fluorodeoxyglucose [¹⁸F-FDG]). Imaging studies were performed in liver cancer cells and xenograft models. The distribution of MMP at the intracellular level was imaged by confocal microscopy. RGD, MMP, and ¹⁸F-FDG were imaged on tumor-bearing mice using PET, CT, X-ray, and multi-wavelength optical imaging modalities. Image data demonstrated that each agent bound to a specific disease target component. The same liver cancer xenograft contained multiple disease markers. Those disease markers were heterogenetically distributed in the same tumor nodule. The molecular imaging agents had different distributions in the whole body and inside the tumor nodule. All target-specific agents yielded high tumor-to-background ratios after injection. In conclusion, target-specific molecular imaging agents can be used to study liver cancer in vitro and in vivo. Noninvasive multimodal/multi-target-specific molecular imaging agents could provide tools to simultaneously study multiple liver cancer components.

Cancer-related disparities and opportunities for intervention in Northern Plains American Indian communities

OBJECTIVES

We examined behavioral trends associated with cancer risk and cancer screening use from 1997 through 2006 among American Indians/Alaska Natives (AI/ANs) in the Northern Plains region (North Dakota, South Dakota, Nebraska, and Iowa) of the United States. We also examined disparities between that population and non-Hispanic white (NHW) people in the Northern Plains and AI/ANs in other regions.

METHODS

We analyzed Behavioral Risk Factor Surveillance System data from the Centers for Disease Control and Prevention for 1997-2000 and 2003-2006. We used age-adjusted Wald Chi-square tests to test the difference between these two periods for AI/ANs and the difference between AI/ANs and NHW people during 2003-2006.

RESULTS

There was no statistically significant improvement among AI/ANs in the Northern Plains region for behaviors associated with cancer risk or cancer screening use, and there was a significant increase in the obesity rate. The prevalence of binge drinking, obesity, and smoking among AI/ANs in the Northern Plains was significantly higher than among NHW people in the same region and among AI/AN populations in other regions. Although the percentage of cancer screening use was similar for all three groups, the use of sigmoidoscopy/colonoscopy was significantly lower among the Northern Plains AI/ANs than among NHW people.

CONCLUSION

These results indicate a need for increased efforts to close the gaps in cancer health disparities between AI/ANs and the general population. Future efforts should focus not only on individual-level changes, but also on system-level changes to build infrastructure to promote healthy living and to increase access to cancer screening.

Health journalism internships: a social marketing strategy to address health disparities

The USA seeks to eliminate health disparities by stimulating the rapid uptake of health-promoting behaviors within disadvantaged communities. A health journalism internship incorporates social marketing strategies to increase communities' access to cancer information, while helping the interns who are recruited from underrepresented communities gain admission to top graduate schools. Interns are taught basic health journalism skills that enable them to create immediate streams of cancer-related press releases for submission to community newspapers. Interns are charged with the social responsibility of continuing this dissemination process throughout their careers. Intermediate outcomes are measured as mediators of distal behavioral change goals.

Race and ethnicity in access to and outcomes of liver transplantation: a critical literature review

Racial/ethnic disparities in access to and outcomes of liver transplantation are an important topic given the increasing diversity in the United States. Most reports on this topic predate the advent of allocation based on the model for end-stage liver disease (MELD). For many patients with a variety of lethal conditions, liver transplantation is the only effective therapy, signifying the importance of equitable access to care. Racial/ethnic disparities have been described at various steps of the liver transplant process, including liver disease prevalence and treatment, access to a transplant center and its waitlist, receipt of a liver transplant and posttransplant outcomes. The purpose of this minireview is to critically evaluate the published literature on racial/ethnicity-based disparities in liver disease prevalence and treatment, transplant center referral, transplant rates and posttransplant outcomes. We identify the shortcomings of previous reports and detail the barriers to completing properly constructed analyses, particularly emphasizing deficits in requisite data and the need for improved study design. Understanding the nature of race/ethnicity-based disparities in liver transplantation is necessary to improve research initiatives, policy design and serves the broader responsibility of providing the highest quality care to all patients with liver disease.

Changes in cancer incidence patterns among a northeastern American Indian population: 1955-1969 versus 1990-2004

PURPOSE

This manuscript examines shifts in patterns of cancer incidence among the Seneca Nation of Indians (SNI) for the interval 1955-1969 compared to 1990-2004.

METHODS

A retrospective cohort design was used to examine cancer incidence among the SNI during 2 time intervals: 1955-1969 and 1990-2004. Person-years at risk were multiplied by cancer incidence rates for New York State, exclusive of New York City, over 5-year intervals. A computer-aided match with the New York State Cancer Registry was used to identify incident cancers. Overall and site-specific standardized incidence ratios (SIRs = observed/expected x 100), and 95% confidence intervals (CIs), were calculated for both time periods.

RESULTS

During the earlier interval, deficits in overall cancer incidence were noted among males (SIR = 56, CI 36-82) and females (SIR = 71, CI 50-98), and for female breast cancers (SIR = 21, CI 4-62). During the more recent intervals, deficits in overall cancer incidence persisted among both genders (males SIR = 63, CI 52-77; females SIR = 67, CI 55-80). Deficits were also noted among males for cancers of the lung (SIR = 60, CI 33-98), prostate (SIR = 51, CI = 33-76) and bladder (SIR = 17, CI = 2-61) and among females for breast (SIR = 33, CI = 20-53) and uterus (SIR = 36, CI = 10-92). No cancer sites demonstrated increased incidence. Persons ages 60-69 years, 70-79 years, and ages 80+ years tended to exhibit deficits in overall incidence.

CONCLUSIONS

Despite marked changes over time, deficits in overall cancer incidence have persisted between the time intervals studied. Tribal-specific cancer data are important for the development and implementation of comprehensive cancer control plans which align with local needs.

Introduction to the supplement on cancer in the American Indian and Alaska Native populations in the United States

The collection of papers in this Supplement combines cancer incidence data from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results program, enhanced by record linkages and geographic factors, to provide a comprehensive description of the cancer burden in the American Indian/Alaska Native population in the United States. Cancer incidence rates among this population varied widely, sometimes more than 5-fold, by geographic region.