Quality of cancer registry birthplace data for Hispanics living in the United States

Ethnic Disparities in Early-Onset Gastric Cancer: A Population-Based Study in Texas and California

BACKGROUND

Incidence rates of gastric cancer are increasing in young adults (age <50 years), particularly among Hispanic persons. We estimated incidence rates of early-onset gastric cancer (EOGC) among Hispanic and non-Hispanic White persons by census tract poverty level and county-level metro/nonmetro residence.

METHODS

We used population-based data from the California and Texas Cancer Registries from 1995 to 2016 to estimate age-adjusted incidence rates of EOGC among Hispanic and non-Hispanic White persons by year, sex, tumor stage, census tract poverty level, metro versus nonmetro county, and state. We used logistic regression models to identify factors associated with distant stage diagnosis.

RESULTS

Of 3,047 persons diagnosed with EOGC, 73.2% were Hispanic White. Incidence rates were 1.29 [95% confidence interval (CI), 1.24-1.35] and 0.31 (95% CI, 0.29-0.33) per 100,000 Hispanic White and non-Hispanic White persons, respectively, with consistently higher incidence rates among Hispanic persons at all levels of poverty. There were no statistically significant associations between ethnicity and distant stage diagnosis in adjusted analysis.

CONCLUSIONS

There are ethnic disparities in EOGC incidence rates that persist across poverty levels.

IMPACT

EOGC incidence rates vary by ethnicity and poverty; these factors should be considered when assessing disease risk and targeting prevention efforts.

Cancer Epidemiology in Hispanic Populations: What Have We Learned and Where Do We Need to Make Progress?

The Hispanic/Latino(x) population (H/L) in the United States of America is heterogeneous and fast growing. Cancer is the number one cause of death among H/Ls, accounting for 21% of deaths. Whereas for the most common cancers, incidence rates are lower in H/Ls compared with non-H/L White (NHW) individuals, H/Ls have a higher incidence of liver, stomach, cervical, penile, and gallbladder cancers. H/L patients tend to be diagnosed at more advanced stages for breast, colorectal, prostate, and lung cancers, and melanoma compared with NHW individuals. Etiologic and cancer outcomes research among H/Ls lags other populations. In this review, we provide a summary of challenges, opportunities, and research priorities related to cancer etiology, cancer outcomes, and survivorship to make progress in addressing scientific gaps. Briefly, we prioritize the need for more research on determinants of obesity, nonalcoholic fatty liver disease and its progression to liver cancer, stomach and gallbladder cancers, and pediatric acute lymphoblastic leukemia. We emphasize the need to improve cancer screening, early detection of cancer, and survivorship care. We highlight critical resources needed to make progress in cancer epidemiologic studies among H/L populations, including the importance of training the next generation of cancer epidemiologists conducting research in H/Ls.

The quality of social determinants data in the electronic health record: a systematic review

OBJECTIVE

The aim of this study was to collect and synthesize evidence regarding data quality problems encountered when working with variables related to social determinants of health (SDoH).

MATERIALS AND METHODS

We conducted a systematic review of the literature on social determinants research and data quality and then iteratively identified themes in the literature using a content analysis process.

RESULTS

The most commonly represented quality issue associated with SDoH data is plausibility (n = 31, 41%). Factors related to race and ethnicity have the largest body of literature (n = 40, 53%). The first theme, noted in 62% (n = 47) of articles, is that bias or validity issues often result from data quality problems. The most frequently identified validity issue is misclassification bias (n = 23, 30%). The second theme is that many of the articles suggest methods for mitigating the issues resulting from poor social determinants data quality. We grouped these into 5 suggestions: avoid complete case analysis, impute data, rely on multiple sources, use validated software tools, and select addresses thoughtfully.

DISCUSSION

The type of data quality problem varies depending on the variable, and each problem is associated with particular forms of analytical error. Problems encountered with the quality of SDoH data are rarely distributed randomly. Data from Hispanic patients are more prone to issues with plausibility and misclassification than data from other racial/ethnic groups.

CONCLUSION

Consideration of data quality and evidence-based quality improvement methods may help prevent bias and improve the validity of research conducted with SDoH data.

Population-Based Analysis of Differences in Gastric Cancer Incidence Among Races and Ethnicities in Individuals Age 50 Years and Older

BACKGROUND & AIMS

There are racial and ethnic differences in the incidence of gastric adenocarcinoma worldwide and in the US. Based on a decision analysis, screening for noncardia gastric adenocarcinoma might be cost-effective for non-White individuals 50 years or older. However, a lack of precise, contemporary information on gastric adenocarcinoma incidence in specific anatomic sites for this age group has impeded prevention and early detection programs in the US. We aimed to estimate the differences in gastric adenocarcinoma incidence in specific anatomic sites among races and ethnicities in individuals 50 years or older.

METHODS

We analyzed California Cancer Registry data from 2011 through 2015 to estimate incidences of gastric adenocarcinoma in specific anatomic sites for non-Hispanic White (NHW), non-Hispanic Black, Hispanic, and the 7 largest Asian American populations. We calculated the differential incidence between non-White groups and NHW using incidence rate ratios and 95% confidence intervals (CIs).

RESULTS

Compared with NHW subjects, all non-White groups had significantly higher incidences of noncardia gastric adenocarcinoma; the incidence was highest among Korean American men 50 years and older (70 cases per 100,000). Compared with NHW subjects 50 years and older, the risk of noncardia gastric adenocarcinoma was 1.8-fold (95% CI, 1.37-2.31) to 7.3-fold (95% CI, 5.73-9.19) higher in most non-White groups and 12.0-fold (95% CI, 9.96-14.6) to 14.5-fold (95% CI, 12.5-16.9) higher among Korean American men and women 50 years and older, respectively. Compared with NHW men 50 years and older, all non-White men, except Japanese and Korean American men, had a significantly lower risk of cardia gastric adenocarcinoma.

CONCLUSIONS

We identified several-fold differences in incidences of gastric adenocarcinoma in specific anatomic sites among racial and ethnic groups, with significant age and sex differences. These findings can be used to develop targeted risk reduction programs for gastric adenocarcinoma.

Nativity, ethnic enclave residence, and breast cancer survival among Latinas: Variations between California and Texas

BACKGROUND

Among Latinas with breast cancer, residence in an ethnic enclave may be associated with survival. However, findings from prior studies are inconsistent.

METHODS

The authors conducted parallel analyses of California and Texas cancer registry data for adult (aged ≥18 years) Latinas who were diagnosed with invasive breast cancer from 1996 to 2005, with follow-up through 2014. Existing indices applied to tract-level 2000 US Census data were used to measure Latinx enclaves and neighborhood socioeconomic status (nSES). Multivariable Cox proportional hazard models were fit for all-cause and breast cancer-specific survival adjusted for year of diagnosis, patient age, nativity (with multiple imputation), tumor stage, histology, grade, size, and clustering by census tract.

RESULTS

Among 38,858 Latinas, the majority (61.3% in California and 70.5% in Texas) lived in enclaves. In fully adjusted models for both states, foreign-born women were found to be more likely to die of breast cancer and all causes when compared with US-born women. Living in enclaves and in neighborhoods with higher SES were found to be independently associated with improved survival from both causes. When combined into a 4-level variable, those in low nSES nonenclaves had worse survival for both causes compared with those living in low nSES enclaves and, in the all-cause but not breast cancer-specific models, those in high nSES neighborhoods, regardless of enclave status, had improved survival from all causes.

CONCLUSIONS

Applying the same methods across 2 states eliminated previously published inconsistent associations between enclave residence and breast cancer survival. Future studies should identify specific protective effects of enclave residence to inform interventions.

Colorectal cancer incidence among Hispanics and non-Hispanic Whites in the United States

PURPOSE

Colorectal cancer (CRC) incidence has declined over the past two decades; however, these declines have not occurred equally in all populations. To better understand the impact of CRC among Hispanics, we examined incidence trends by age and Hispanic ethnicity.

METHODS

Using data from the National Program of Cancer Registries and the Surveillance, Epidemiology, and End Results Program, we estimated CRC incidence rates during the period 2001-2014, and across all 50 U.S. states. We estimated incidence rates in younger (age < 50 years) and older (age ≥ 50 years) adults by anatomic subsite and stage at diagnosis, separately for non-Hispanic Whites and Hispanic Whites.

RESULTS

CRC incidence rates declined among older (age ≥ 50 years) Whites and Hispanics, but Whites experienced a greater decline (31% vs. 27% relative decline among Hispanics). In contrast to older adults, there were continued increases in CRC incidence from 2001 to 2014 among younger (age 20-49 years) adults. The largest relative increases in incidence occurred in Hispanics aged 20-29 years (90% vs. 50% relative increase among Whites).

CONCLUSIONS

Opposing incidence trends in younger versus older Hispanics may reflect generational differences in CRC risk by birth cohort, as well as environmental exposures and lifestyle-related risk factors associated with immigration and acculturation.

Contribution of clinical and socioeconomic factors to differences in breast cancer subtype and mortality between Hispanic and non-Hispanic white women

PURPOSE

To assess tumor subtype distribution and the relative contribution of clinical and sociodemographic factors on breast cancer survival between Hispanic and non-Hispanic whites (NHWs).

METHODS

We analyzed data from the California Cancer Registry, which included 29,626 Hispanic and 99,862 NHW female invasive breast cancer cases diagnosed from 2004 to 2014. Logistic regression was used to assess ethnic differences in tumor subtype, and Cox proportional hazard modeling to assess differences in breast cancer survival.

RESULTS

Hispanics compared to NHWs had higher odds of having triple-negative (OR = 1.29; 95% CI 1.23-1.35) and HER2-overexpressing tumors (OR = 1.19; 95% CI 1.14-1.25 [HR-] and OR = 1.39; 95% CI 1.31-1.48 [HR+]). In adjusted models, Hispanic women had a higher risk of breast cancer mortality than NHW women (mortality rate ratio [MRR] = 1.24; 95% CI 1.19-1.28). Clinical factors accounted for most of the mortality difference (MRR = 1.05; 95% CI 1.01-1.09); however, neighborhood socioeconomic status (SES) and health insurance together accounted for all of the mortality difference (MRR = 1.01; 95% CI 0.97-1.05).

CONCLUSIONS

Addressing SES disparities, including increasing access to health care, may be critical to overcoming poorer breast cancer outcomes in Hispanics.

Prognostic significance of marital status in breast cancer survival: A population-based study

Research shows that married cancer patients have lower mortality than unmarried patients but few data exist for breast cancer. We assessed total mortality associated with marital status, with attention to differences by race/ethnicity, tumor subtype, and neighborhood socioeconomic status (nSES). We included, from the population-based California Cancer Registry, women ages 18 and older with invasive breast cancer diagnosed between 2005 and 2012 with follow-up through December 2013. We estimated mortality rate ratios (MRR) and 95% confidence intervals (CI) for total mortality by nSES, race/ethnicity, and tumor subtype. Among 145,564 breast cancer cases, 42.7% were unmarried at the time of diagnosis. In multivariable-adjusted models, the MRR (95% CI) for unmarried compared to married women was 1.28 (1.24-1.32) for total mortality. Significant interactions were observed by race/ethnicity (P<0.001), tumor subtype (P<0.001), and nSES (P = 0.009). Higher MRRs were observed for non-Hispanic whites and Asians/Pacific Islanders than for blacks or Hispanics, and for HR+/HER2+ tumors than other subtypes. Assessment of interactive effect between marital status and nSES showed that unmarried women living in low SES neighborhoods had a higher risk of dying compared with married women in high SES neighborhoods (MRR = 1.60; 95% CI: 1.53-1.67). Unmarried breast cancer patients have higher total mortality than married patients; the association varies by race/ethnicity, tumor subtype, and nSES. Unmarried status should be further evaluated as a breast cancer prognostic factor. Identification of underlying causes of the marital status associations is needed to design interventions that could improve survival for unmarried breast cancer patients.

Cancer incidence profile in sub-Saharan African-born blacks in the United States: Similarities and differences with US-born non-Hispanic blacks

BACKGROUND

Sub-Saharan African-born blacks (ABs) are one of the fastest-growing populations in the United States. However, to the authors' knowledge, data regarding the cancer burden in this group are lacking, which would inform targeted cancer prevention and control.

METHODS

The authors calculated age-standardized proportional incidence ratios (PIRs) comparing the frequency of the top 15 cancers in ABs with that of US-born non-Hispanic blacks (USBs) by sex and region of birth using incidence data for 2000 through 2012 from the Surveillance, Epidemiology, and End Results (SEER 17) program.

RESULTS

Compared with USBs, ABs had significantly higher PIRs of infection-related cancers (liver, stomach, and Kaposi sarcoma), blood cancers (leukemia and non-Hodgkin lymphoma), prostate cancer, and thyroid cancers (females only). For example, the PIR for Kaposi sarcoma in AB versus USB women was 12.06 (95% confidence interval [95% CI], 5.23-18.90). In contrast, ABs had lower PIRs for smoking-related and colorectal cancers (eg, for lung cancer among men, the PIR was 0.30 [95% CI, 0.27-0.34]). Furthermore, cancer occurrence in ABs versus USBs varied by region of birth. For example, the higher PIRs for liver cancer noted among male ABs (PIR, 3.57; 95% CI, 1.79-5.35) and for thyroid cancer in female ABs (PIR, 3.03; 95% CI, 2.03-4.02) were confined to Eastern African-born blacks, whereas the higher PIR for prostate cancer (PIR, 1.90; 95% CI, 1.78, 2.02) was confined to Western African-born blacks.

CONCLUSIONS

The cancer incidence profile of ABs is different from that of USBs and varies by region of birth, suggesting differences in environmental, cultural, social, and genetic factors. The findings of the current study could stimulate etiologic research and help to inform targeted interventions. Cancer 2017;123:3116-24. © 2017 American Cancer Society.

Variation in risk and outcomes of Epstein-Barr virus-associated breast cancer by epidemiologic characteristics and virus detection strategies: an exploratory study

PURPOSE

A relationship of Epstein-Barr virus (EBV) and breast cancer etiology and outcome may have clinical utility and potential to enhance understanding of tumor biology. Research to date has yielded variable results, likely reflecting differing virus detection assays and unaddressed epidemiologic heterogeneity across studies.

METHODS

Applying our novel, five-target assay detection strategy in an exploratory study, we examined demographic, clinical, and tumor characteristics, and overall survival, associated with EBV positivity in breast adenocarcinomas from 59 non-Hispanic white and 68 Hispanic women sampled by age (<50, 50+) and stage (localized, regional/remote) and examined associations based on single assay targets.

RESULTS

EBV was localized only to lymphocytes. Nevertheless, viral prevalence, although low, varied across patient subgroups. Adjusted odds ratios (OR) for EBV positivity were lower for younger Hispanic than white women (p _interaction = 0.05), and marginally higher for larger [OR (95% confidence intervals) 1.03 (1.00-1.05) per mm increase] and right-sided [2.8 (0.97-7.8)] tumors. In whites, ORs were marginally higher for larger tumors [1.04 (1.00-1.07)] and marginally lower for age 50+ [0.24 (0.06-1.03)]; in Hispanics, ORs were higher for ER negative [5.6 (1.1-30.5)], and marginally higher for right-sided, tumors [5.8 (0.94-36.2)]. Survival was suggestively poorer for EBV-positive than EBV-negative tumors in older women with localized disease. EBV associations differed across single assay targets, indicating variation in prior findings likely due to assay performance.

CONCLUSIONS

The differing EBV associations by age and race/ethnicity suggest a non-random role of EBV in breast cancer and support further study using multi-target assays, relevant epidemiologic design, and a larger study sample.

Hispanic and Immigrant Paradoxes in U.S. Breast Cancer Mortality: Impact of Neighborhood Poverty and Hispanic Density

To test the Hispanic and Immigrant Paradoxes-i.e., survival advantages despite a worse risk factor profile-and the modifying role of neighborhood context, we examined associations between patient ethnicity, birthplace, neighborhood Hispanic density and neighborhood poverty among 166,254 female breast cancer patients diagnosed 1995-2009 in Texas, U.S. Of all, 79.9% were non-Hispanic White, 15.8% Hispanic U.S.-born, and 4.2% Hispanic foreign-born. We imputed birthplace for the 60.7% of Hispanics missing birthplace data using multiple imputation. Shared frailty Cox proportional hazard models (patients nested within census tracts) adjusted for age, diagnosis year, stage, grade, histology, urban/rural residence, and local mammography capacity. Whites (vs. U.S.-born Hispanics) had increased all-cause and breast cancer mortality. Foreign-born (vs. U.S.-born) Hispanics had increased all-cause and breast cancer mortality. Living in higher Hispanic density neighborhoods was generally associated with increased mortality, although associations differed slightly in magnitude and significance by ethnicity, birthplace, and neighborhood poverty. We found no evidence of an Immigrant Paradox and some evidence of a Hispanic Paradox where protective effects were limited to U.S.-born Hispanics. Contrary to prior studies, foreign birthplace and residence in higher Hispanic density neighborhoods were associated with increased mortality. More research on intersections between ethnicity, birthplace and neighborhood context are needed.

Black Heterogeneity in Cancer Mortality: US-Blacks, Haitians, and Jamaicans

INTRODUCTION

The quantitative intraracial burden of cancer incidence, survival and mortality within black populations in the United States is virtually unknown.

METHODS

We computed cancer mortality rates of US- and Caribbean-born residents of Florida, specifically focusing on black populations (United States, Haiti, Jamaica) and compared them using age-adjusted mortality ratios obtained from Poisson regression models. We compared the mortality of Haitians and Jamaicans residing in Florida to populations in their countries of origin using Globocan.

RESULTS

We analyzed 185,113 cancer deaths from 2008 to 2012, of which 20,312 occurred in black populations. The overall risk of death from cancer was 2.1 (95% CI: 1.97-2.17) and 1.6 (95% CI: 1.55-1.71) times higher for US-born blacks than black Caribbean men and women, respectively (P < .001).

CONCLUSIONS

Race alone is not a determinant of cancer mortality. Among all analyzed races and ethnicities, including Whites and Hispanics, US-born blacks had the highest mortality rates while black Caribbeans had the lowest. The biggest intraracial difference was observed for lung cancer, for which US-blacks had nearly 4 times greater mortality risk than black Caribbeans. Migration from the islands of Haiti and Jamaica to Florida resulted in lower cancer mortality for most cancers including cervical, stomach, and prostate, but increased or stable mortality for 2 obesity-related cancers, colorectal and endometrial cancers. Mortality results in Florida suggest that US-born blacks have the highest incidence rate of "aggressive" prostate cancer in the world, rather than Caribbean men.

Differences in marital status and mortality by race/ethnicity and nativity among California cancer patients

BACKGROUND

It has been observed that married cancer patients have lower mortality rates than unmarried patients, but data for different racial/ethnic groups are scarce. The authors examined the risk of overall mortality associated with marital status across racial/ethnic groups and sex in data from the California Cancer Registry.

METHODS

California Cancer Registry data for all first primary invasive cancers diagnosed from 2000 through 2009 for the 10 most common sites of cancer-related death for non-Hispanic whites (NHWs), blacks, Asians/Pacific Islanders (APIs), and Hispanics were used to estimate multivariable hazard ratios (HRs) and 95% confidence intervals (CIs) for marital status in relation to overall mortality by race/ethnicity and sex. The study cohort included 393,470 male and 389,697 female cancer patients and 204,007 and 182,600 deaths from all causes, respectively, through December 31, 2012.

RESULTS

All-cause mortality was higher in unmarried patients than in married patients, but there was significant variation by race/ethnicity. Adjusted HRs (95% CIs) ranged from 1.24 (95% CI, 1.23-1.26) in NHWs to 1.11 (95% CI, 1.07-1.15) in APIs among males and from 1.17 (95% CI, 1.15-1.18) in NHWs to 1.07 (95% CI, 1.04-1.11) in APIs among females. All-cause mortality associated with unmarried status compared with married status was higher in US-born API and Hispanic men and women relative to their foreign-born counterparts.

CONCLUSIONS

For patients who have the cancers that contribute most to mortality, being unmarried is associated with worse overall survival compared with being married, with up to 24% higher mortality among NHW males but only 6% higher mortality among foreign-born Hispanic and API females. Future research should pursue the identification of factors underlying these associations to inform targeted interventions for unmarried cancer patients. Cancer 2016;122:1570-8. © 2016 American Cancer Society.

Birthplace and esophageal cancer incidence patterns among Asian-Americans

The incidence of esophageal adenocarcinoma in the United States has risen rapidly over the last 30 years, whereas the incidence of esophageal squamous cell carcinoma has fallen dramatically. In contrast, parts of Asia have extremely high rates of squamous cell carcinoma, but virtually no adenocarcinoma. Within the United States, Asian-Americans as a whole, have low rates of esophageal adenocarcinoma and higher rates of squamous cell carcinoma. It is unclear what the patterns are for those Asians born in the United States. The relative influence of ethnicity and environment on the incidence of esophageal cancer in this population is unknown. We identified all cases of esophageal adenocarcinoma and squamous cell carcinoma from the California Cancer Registry 1988-2004, including 955 cases among 6 different Asian ethnicities. Time trends were examined using Joinpoint software to calculate the annual percentage changes in regression models. Rates of esophageal squamous cell carcinoma varied substantially among different Asian ethnic groups, but squamous cell carcinoma was much more common than adenocarcinoma in both foreign-born and US-born Asian-Americans. Rates of squamous cell carcinoma were slightly higher among US-born Asian men (4.0 per 100,000) compared with foreign-born Asian men (3.2 per 100,000) and White men (2.2 per 100,000), P = 0.03. Rates of adenocarcinoma were also slighter higher among US-born Asian men (1.2 per 100,000) compared with foreign-born Asian men (0.7 per 100,000), P = 0.01. Rates of squamous cell carcinoma decreased for both US-born and foreign-born Asians during this period, whereas adenocarcinoma remained low and stable. These results provide better insight into the genetic and environmental factors affecting the changing incidence of esophageal cancer histologies in the United States and Asia.

Lack of improvement in survival rates for women under 50 with endometrial cancer, 2000-2011

PURPOSE

To assess how first course of treatment affects cancer-specific survival in women diagnosed with endometrial cancer younger than 50 years old.

METHODS

Public-use data from the Surveillance, Epidemiology, and End Results program were used. The study included 82,721 women diagnosed with primary, invasive endometrial cancer between 2000 and 2011. We assessed type of treatment using Cox's proportional hazards models to determine survival disparity by age and stage.

RESULTS

Cancer-specific survival significantly improved for those aged ≥50 years with late stage, but did not improve for those <50. First course of treatment significantly affected cancer-specific survival for endometrial cancer patients. Regardless of age, survival was greatly improved for late-stage patients who received a combination of surgery and radiation [hazard ratio (HR) 0.62 [95 % confidence interval (CI) 0.47-0.78] and 0.64 (95 % CI 0.59-0.68)] compared to those who received total hysterectomy with removal of ovaries and tubes. However, the proportion of patients who received combination therapy decreased over time. The magnitude of decrease was larger in patients <50 than in those aged ≥50. Overall, about 24-57 % of the difference in cancer-specific survival over time in patients aged <50 was explained by their initial treatment.

CONCLUSIONS

Improvement in cancer-specific survival was only seen in older women with late-stage diagnosis. Despite improvements in diagnoses and treatments, the difference in age-specific survival indicates that more should be done to understand why these rates are not improving for those younger than 50 years old.

Assessing race and ethnicity data quality across cancer registries and EMRs in two hospitals

BACKGROUND

Measurement of patient race/ethnicity in electronic health records is mandated and important for tracking health disparities.

OBJECTIVE

Characterize the quality of race/ethnicity data collection efforts.

METHODS

For all cancer patients diagnosed (2007-2010) at two hospitals, we extracted demographic data from five sources: 1) a university hospital cancer registry, 2) a university electronic medical record (EMR), 3) a community hospital cancer registry, 4) a community EMR, and 5) a joint clinical research registry. The patients whose data we examined (N = 17 834) contributed 41 025 entries (range: 2-5 per patient across sources), and the source comparisons generated 1-10 unique pairs per patient. We used generalized estimating equations, chi-squares tests, and kappas estimates to assess data availability and agreement.

RESULTS

Compared to sex and insurance status, race/ethnicity information was significantly less likely to be available (χ(2 )> 8043, P < .001), with variation across sources (χ(2 )> 10 589, P < .001). The university EMR had a high prevalence of "Unknown" values. Aggregate kappa estimates across the sources was 0.45 (95% confidence interval, 0.45-0.45; N = 31 276 unique pairs), but improved in sensitivity analyses that excluded the university EMR source (κ = 0.89). Race/ethnicity data were in complete agreement for only 6988 patients (39.2%). Pairs with a "Black" data value in one of the sources had the highest agreement (95.3%), whereas pairs with an "Other" value exhibited the lowest agreement across sources (11.1%).

DISCUSSION

Our findings suggest that high-quality race/ethnicity data are attainable. Many of the "errors" in race/ethnicity data are caused by missing or "Unknown" data values.

CONCLUSIONS

To facilitate transparent reporting of healthcare delivery outcomes by race/ethnicity, healthcare systems need to monitor and enforce race/ethnicity data collection standards.

Improving Hospital Reporting of Patient Race and Ethnicity--Approaches to Data Auditing

OBJECTIVE

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.

CONCLUSIONS

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.

Nativity and neighborhood characteristics and cervical cancer stage at diagnosis and survival outcomes among Hispanic women in California

OBJECTIVES

We examined stage of diagnosis and survival after cervical cancer among Hispanic women, and their associations with Hispanic nativity, and explored whether neighborhood socioeconomic status (SES) and residence in a Hispanic enclave modify the association of nativity with stage and survival.

METHODS

We used California Cancer Registry data (1994-2009) to identify 7958 Hispanic women aged 21 years and older with invasive cervical cancer. We used logistic and Cox proportional hazards models to estimate the associations between stage and mortality with nativity, neighborhood factors, and other covariates.

RESULTS

Foreign-born women had similar adjusted relative odds of being diagnosed with stages II through IV (vs stage I) cervical cancer compared with US-born Hispanic women. However, among foreign-born women, those in low-SES-low-enclave neighborhoods were more likely to have late-stage disease than those in high-SES-low-enclave neighborhoods (adjusted odds ratio=1.91; 95% confidence interval=1.18, 3.07). Foreign-born women had lower cervical cancer mortality (adjusted hazard ratio=0.67; 95% confidence interval=0.58, 0.76) than US-born women, but only in high enclaves.

CONCLUSIONS

Among Hispanic women, nativity, neighborhood enclaves, and SES interact in their influence on stage and survival of cervical cancer.

Colorectal cancer mortality among Hispanics in California: differences by neighborhood socioeconomic status and nativity

BACKGROUND

Socioeconomic status (SES) plays an important role in colorectal cancer (CRC) mortality, although the independent and joint effects with nativity and neighborhood factors have yet to be evaluated.

METHODS

With nearly one-third of all US Hispanics residing in California, the authors obtained information from the California Cancer Registry to examine the associations between neighborhood SES and mortality in all 33,146 Hispanic individuals diagnosed with CRC from 1988 through 2010, with a particular focus on associations among US-born and foreign-born Hispanics. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CI) for overall and CRC-specific mortality.

RESULTS

Hispanics residing in lower SES neighborhoods demonstrated a higher rate of overall and CRC-specific mortality than those residing in high SES neighborhoods (SES quintile 1[low] vs quintile 5 [high]: HR, 1.15 [95% CI, 1.05-1.26] and HR, 1.16 [95% CI, 1.03-1.30], respectively). Nativity modified the associations between SES and mortality (P for interaction, .02 for overall and P for interaction, .01 for CRC-specific mortality) such that the SES associations were observed only among US-born (P for trend < .01 for overall and CRC-specific mortality) but not among foreign-born Hispanics.

CONCLUSIONS

Neighborhood SES demonstrates significant differential effects on overall and CRC-specific mortality between US-born and foreign-born Hispanics. Future efforts should investigate the underlying contextual and individual-level factors that could account for these differential associations by nativity.

Hodgkin lymphoma incidence in California Hispanics: influence of nativity and tumor Epstein-Barr virus

PURPOSE

For classical Hodgkin lymphoma (HL), migrant studies could elucidate contributions of environmental factors (including Epstein-Barr virus (EBV)) to the lower rates in non-whites. Given the well-described etiologic complexity of HL, this research requires a large, immigrant population, such as California Hispanics.

METHODS

With 1988-2004 California Cancer Registry data (2,595 Hispanic, 8,637 white HL cases) and tumor cell EBV status on a subset (218 Hispanics, 656 whites), we calculated ethnicity- and nativity-specific HL incidence rates simultaneously by age, sex, and histologic subtype, and tumor cell EBV prevalence.

RESULTS

Compared with white rates, Hispanic HL rates were lower overall (70 %) and for nodular sclerosis HL, particularly among young adults (60-65 % for females). However, they were higher among children (200 %) and older adults, and for mixed cellularity HL. Compared with rates in foreign-born Hispanics, rates in US-born Hispanics were higher among young adults (>threefold in females), lower for children and adults over age 70, and consistently intermediate compared with rates in whites. EBV tumor prevalence was 67, 32, and 23 % among foreign-born Hispanics, US-born Hispanics, and whites, respectively, although with variation by age, sex, and histology.

CONCLUSIONS

Findings strongly implicate environmental influences, such as nativity-related sociodemographic differences, on HL occurrence. In addition, lower young adult rates and higher EBV prevalence in US-born Hispanics than in whites raise questions about the duration/extent of environmental change for affecting HL rates and also point to ethnic differences in genetic susceptibility. Lesser variation in mixed cellularity HL rates and greater variation in rates for females across groups suggest less modifiable factors interacting with environmental influences.

Continued rapid increase in thyroid cancer incidence in california: trends by patient, tumor, and neighborhood characteristics

BACKGROUND

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.

METHODS

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 U.S. Census. Incidence rates and 95% confidence intervals (CI) were calculated and incidence trends were evaluated using Joinpoint regression to evaluate the timing and magnitude of change [annual percentage change (APC) and rate ratios].

RESULTS

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.

CONCLUSIONS

Although some variation in the magnitude or temporality of the increase in thyroid cancer incidence exists across subgroups, the patterns (i) suggest that changes in diagnostic technology alone do not account for the observed trends and (ii) point to the importance of modifiable behavioral, lifestyle, or environmental factors in understanding this epidemic.

IMPACT

Given the dramatic and continued increase in thyroid cancer incidence rates, studies addressing the causes of these trends are critical. Cancer Epidemiol Biomarkers Prev; 23(6); 1067-79. ©2014 AACR.

Impact of socioeconomic status and ethnic enclave on cervical cancer incidence among Hispanics and Asians in California

OBJECTIVE

This study aimed to evaluate the incidence of cervical cancer by nativity [United States (US) versus non-US], neighborhood socioeconomic status and ethnic enclave among Hispanics and Asians in California.

METHODS

Using data from the California Cancer Registry, information on all primary invasive cervical cancer (Cca) patients diagnosed in California from January 1, 1990 through December 31, 2004 was obtained. We analyzed the influence of enclave, socioeconomic status and nativity on Cca incidence.

RESULTS

Among the 22,189 Cca cases diagnosed between 1990 and 2004, 50% were non-Hispanic white, 39% Hispanic and 11% Asian women, and 63% US-born. Seventy percent of the Cca cases were squamous cell carcinoma, 19% adenocarcinoma and 11% other histologies. Higher incidence of Cca was observed in high enclave (76%) and low socioeconomic status (70%) neighborhoods. By ethnic group, US-born women showed lower rates of squamous cell carcinoma compared to foreign-born women. Hispanics living in low socioeconomic and high enclave had 12.7 times higher rate of Cca than those living in high socioeconomic, low enclave neighborhoods. For Asian women incidence rates were 6 times higher in the low socioeconomic, high enclave neighborhoods compared to those living in high socioeconomic, low enclave neighborhoods.

CONCLUSION

More targeted outreach to increase Pap smear screening and human papilloma virus vaccination for women living in high enclave neighborhoods can help decrease the incidence of Cca in these groups of women.

Immigration factors and prostate cancer survival among Hispanic men in California: does neighborhood matter?

BACKGROUND

Hispanics are more likely than other racial/ethnic groups in the United States to be diagnosed with later stage of prostate cancer, yet they have lower prostate cancer mortality rates. The authors evaluated the impact of nativity and neighborhood-level Hispanic ethnic enclave on prostate cancer survival among Hispanics.

METHODS

A total of 35,427 Hispanic men diagnosed with invasive prostate cancer from 1995 through 2008 in the California Cancer Registry were studied; vital status data were available through 2010. Block group-level neighborhood measures were developed from US Census data. Stage-stratified Cox proportional hazards models were used to assess the effect of nativity and ethnic enclave on prostate cancer survival.

RESULTS

In models adjusted for neighborhood socioeconomic status and other individual factors, foreign-born Hispanics were found to have a significantly lower risk of prostate cancer survival (hazards ratio [HR], 0.81; 95% confidence interval [95% CI], 0.75-0.87). Living in an ethnic enclave appeared to modify this effect, with the survival advantage slightly more pronounced in the high ethnic enclave neighborhoods (HR, 0.78; 95% CI, 0.71-0.86) compared with low ethnic enclave neighborhoods (HR, 0.86; 95% CI, 0.76-0.98).

CONCLUSIONS

Despite lower socioeconomic status, Hispanic immigrants have better survival after prostate cancer than US-born Hispanics and this pattern was more striking among those living in ethnic enclaves. Identifying the modifiable individual and neighborhood-level factors that facilitate this survival advantage in Hispanic immigrants may help to inform specific interventions to improve survival among all patients.

Heterogeneity of breast cancer subtypes and survival among Hispanic women with invasive breast cancer in California

There are limited data regarding breast cancer subtypes among Hispanic women. The current study assessed the distribution and prognosis of molecular subtypes defined by joint expression of the hormone receptors (HR; estrogen and progesterone) and human epidermal growth factor receptor 2 (HER2). Using California Cancer Registry data, we identified Hispanic women diagnosed with invasive breast cancer from 2005 to 2010. Breast cancer subtypes were defined as HR+/HER2-, HR+/HER2+, HR-/HER2+, and HR-/HER2- (triple negative). We estimated breast cancer subtype frequencies and used polytomous logistic regression, Kaplan-Meier survival plots and Cox regression to examine differences in relation to demographic and clinical characteristics. Among 16,380 Hispanic women with breast cancer, HR+/HER- subtype was the most common (63 %), followed by triple negative (16 %), HR+/HER2+ (14 %), and HR-/HER2+ (8 %). Women in lower SES neighborhoods had greater risk of triple negative and HR-/HER2+ subtypes relative to HR+/HER2- (p < 0.05). Hispanic women with triple negative and HR-/HER2+ tumors experienced poorer survival than those with HR+/HER- tumors. Breast cancer-specific mortality increased with decreasing SES, relative to the highest SES quintile, from HR = 1.38 for quintile 4 to HR = 1.76 for quintile 1 (lowest SES level). Our findings indicate that Hispanic women residing in low SES neighborhoods had significantly increased risk of developing and dying from HR- than HR+ breast cancers. Similar patterns of subtype frequency and prognosis among California Hispanic women and studies of other racial/ethnic groups underscore the need to better understand the impact of SES on risk factor exposures that increase the risk of breast cancer subtypes with poor prognosis.

Uncovering nativity disparities in cancer patterns: Multiple imputation strategy to handle missing nativity data in the Surveillance, Epidemiology, and End Results data file

BACKGROUND

Although birthplace data are routinely collected in the participating Surveillance, Epidemiology, and End Results (SEER) registries, such data are missing in a nonrandom manner for a large percentage of cases. This hinders analysis of nativity-related cancer disparities. In the current study, the authors evaluated multiple imputation of nativity status among Hispanic patients diagnosed with cervical, prostate, and colorectal cancer and demonstrated the effect of multiple imputation on apparent nativity disparities in survival.

METHODS

Multiple imputation by logistic regression was used to generate nativity values (US-born vs foreign-born) using a priori-defined variables. The accuracy of the method was evaluated among a subset of cases. Kaplan-Meier curves were used to illustrate the effect of imputation by comparing survival among US-born and foreign-born Hispanics, with and without imputation of nativity.

RESULTS

Birthplace was missing for 31%, 49%, and 39%, respectively, of cases of cervical, prostate, and colorectal cancer. The sensitivity of the imputation strategy for detecting foreign-born status was ≥90% and the specificity was ≥86%. The agreement between the true and imputed values was ≥0.80 and the misclassification error was ≤10%. Kaplan-Meier survival curves indicated different associations between nativity and survival when nativity was imputed versus when cases with missing birthplace were omitted from the analysis.

CONCLUSIONS

Multiple imputation using variables available in the SEER data file can be used to accurately detect foreign-born status. This simple strategy may help researchers to disaggregate analyses by nativity and uncover important nativity disparities in regard to cancer diagnosis, treatment, and survival.

Nativity disparities in late-stage diagnosis and cause-specific survival among Hispanic women with invasive cervical cancer: an analysis of Surveillance, Epidemiology, and End Results data

PURPOSE

While cervical cancer screening and risk behaviors have been found to vary among US- and foreign-born Hispanic women, many cancer epidemiology studies have conceptualized Hispanics as a homogenous group. Here, we examine differences in cervical cancer stage at diagnosis and survival among Hispanic women by nativity.

METHODS

We use data from the Surveillance, Epidemiology, and End Results program, 1998-2008. Nativity was based on place of birth and was categorized as US versus foreign born. Distant and regional tumors were classified as late stage, while local tumors were classified as early stage.

RESULTS

Forty-seven percent of cases of invasive cervical cancer among Hispanics were diagnosed at a late stage, and over half of invasive cervical cancer cases were among foreign-born women. Foreign-born Hispanic women were significantly more likely than US-born Hispanics to have late-stage diagnosis, after adjusting for age at diagnosis and tumor histology (adjusted odds ration = 1.09, p value = 0.003). There was heterogeneity in the association between nativity and survival by stage at diagnosis. Among cases with early-stage diagnosis, survival was poorer among foreign-born versus US-born Hispanics after adjusting for age at diagnosis, histology, and cancer-directed therapy [adjusted hazard ratios (HR) = 1.31, p value = 0.030]. However, among cases with late-stage diagnosis, survival was better among foreign-born Hispanics (adjusted HR = 0.81, p value < 0.001).

CONCLUSIONS

We hypothesize that nativity differences in survival may be indicative of diverse risk, screening, and treatment profiles. Given such differences, it may be inappropriate to aggregate Hispanics as a single group for cervical cancer research.

How do social factors explain outcomes in non-small-cell lung cancer among Hispanics in California? Explaining the Hispanic paradox

PURPOSE

Hispanics in the United States have lower age-adjusted mortality resulting from non-small-cell lung cancer (NSCLC) compared with non-Hispanic whites (NHWs). The purpose of this study was to evaluate individual, clinical, and neighborhood factors in survival among Hispanics with NSCLC.

PATIENTS AND METHODS

We performed a retrospective analysis of NHWs and Hispanics with NSCLC between 1998 and 2007 in the California Cancer Registry (follow-up to December 2009). Kaplan-Meier curves depict survival by nativity for Hispanics with NSCLC. Cox proportional hazards models estimated hazard of mortality by race with adjustment for individual (age, sex, marital status), clinical (histologic grade, surgery, irradiation, chemotherapy), and neighborhood factors (neighborhood socioeconomic status, ethnic enclave).

RESULTS

We included 14,280 Hispanic patients with NSCLC. Foreign-born Hispanics had 15% decreased risk of disease-specific mortality resulting from NSCLC compared with NHWs (hazard ratio [HR], 0.85; 95% CI, 0.83 to 0.88) after adjustment for individual, clinical, and neighborhood factors. After adjustment for individual factors, compared with US-born Hispanics, foreign-born Hispanics had 10% decreased risk of disease-specific mortality (HR, 0.90; 95% CI, 0.87 to 0.96). Clinical and neighborhood factors slightly moderated the survival benefit for foreign-born patients. A modestly more pronounced survival advantage was seen for foreign-born Hispanics living in low socioeconomic and high Hispanic enclave neighborhoods as compared with US-born Hispanics (HR, 0.86; 95% CI, 0.81 to 0.90).

CONCLUSION

Foreign-born Hispanics with NSCLC have a decreased risk of disease-specific mortality compared with NHWs and US-born Hispanics with NSCLC. Neighborhood factors slightly moderate this survival advantage. This survival advantage is slightly more pronounced in lower socioeconomic and higher Hispanic enclave neighborhoods.

Understanding the limits of large datasets

Many health professionals use large datasets to answer behavioral, translational, or clinical questions. Understanding the impact of missing data in large databases, such as disease registries, can avoid erroneous interpretations of these data. Using the California Cancer Registry, the authors selected seven common cancers, seven sociodemographic and clinical variables, and the top three reporting sources, as examples of the type of data that would be deemed critical to most studies. The gender variable had no missing data, followed by age (<0.1 % missing), ethnicity (1.7 %), stage (9.8 %), differentiation (39.1 %), and birthplace (41.1 %). Reports from hospitals and clinics had the lowest percentages of missing data. Users of large datasets should anticipate the limitations of missing data to prevent methodological flaws and misinterpretations of research findings. Knowledge of what and how much data may be missing in large datasets can help prevent errors in research conclusions, while better guiding treatment modalities and public health policies and programs.

Racial disparities in Hodgkin's lymphoma: a comprehensive population-based analysis

BACKGROUND

Racial disparity has been investigated in a number of cancers; however, there remains a comparative paucity of data in Hodgkin's lymphoma (HL).

PATIENTS AND METHODS

We examined time-, age-, and gender-specific incidence, disease characteristics, and survival across and within races for adolescent/adult HL (age 10-79 years) diagnosed during 1992-2007 in the SEER 13 registries.

RESULTS

A total of 15 662 HL cases were identified [11,211 non-Hispanic whites, 2067 Hispanics, 1662 blacks, and 722 Asian/Pacific Islanders (A/PI)]. Similar to whites, A/PIs had bimodal age-specific incidence, while blacks and Hispanics did not. Further, HL was significantly more common in Hispanics versus whites age>65 years (7.0/1×10(6) versus 4.5/1×10(6), respectively, P<0.01). By place of birth, US-born Hispanics and A/PIs age 20-39 years had higher incidence of HL versus their foreign-born counterparts (P<0.05), however, rates converged age>40 years. Interestingly, from 1992-1997 to 2003-2007, A/PI incidence rates increased >50% (P<0.001). Moreover, this increase was restricted to US-born A/PI. We also identified a number of disease-related differences based on race. Finally, 5-, 10-, and 15-year overall survival rates were inferior for blacks and Hispanics compared with whites (P<0.005 and P<0.001, respectively) and A/PI (P<0.018 and P<0.001, respectively). These differences persisted on multivariate analysis.

CONCLUSION

Collectively, we identified multiple racial disparities, including survival, in adolescent/adult HL.

Patient, hospital, and neighborhood factors associated with treatment of early-stage breast cancer among Asian American women in California

BACKGROUND

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 are more likely than other groups to have mastectomy or omit radiation after BCS.

METHODS

We applied polytomous logistic regression and recursive partitioning to analyze factors associated with mastectomy, or BCS without radiation, among 20,987 California Asian Americans diagnosed with stage 0 to II breast cancer from 1990 to 2007.

RESULTS

The percentage receiving mastectomy ranged from 40% among U.S.-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 Asian Americans ethnicities, and additional factors including hospital [smaller hospital size, not National Cancer Institute cancer center, low socioeconomic status (SES) patient composition, and high hospital Asian Americans patient composition] and neighborhood characteristics (ethnic enclaves of low SES). These hospital and neighborhood characteristics were also associated with BCS without radiation. Through recursive partitioning, the highest mastectomy subgroups were defined by tumor characteristics such as size and anatomic location, in combination with diagnosis year and nativity.

CONCLUSIONS

Tumor characteristics and, secondarily, patient, hospital, and neighborhood factors are predictors of mastectomy and omission of radiation following BCS among Asian Americans.

IMPACT

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.

Gastric cancer incidence among Hispanics in California: patterns by time, nativity, and neighborhood characteristics

BACKGROUND

Better understanding about gastric cancer incidence patterns among Hispanics by birthplace, socioeconomic status (SES), and acculturation can improve preventive strategies and disease models.

METHODS

Incidence rates, rate ratios, and estimated annual percent change (EAPC) in rates of anatomic and histologic subtype-specific gastric cancer were calculated by age, sex, and nativity among Hispanics using California Cancer Registry data from 1988 through 2004. Incidence rates in 1998 to 2002 were compared by neighborhood SES and Hispanic enclave status according to 2000 US Census data.

RESULTS

Incidence rates of diffuse gastric cancer increased from 1988 through 2004 among foreign-born Hispanic men (EAPC: 3.5%, 95% CI: 1.5%-5.5%) and U.S.-born Hispanic women (EAPC: 3.0%, 95% CI: 0.7%-5.3%). During the same time period, incidence rates of intestinal gastric cancer declined significantly and both cardia and noncardia gastric cancer were steady or declined among foreign-born and U.S.-born Hispanic men and women. Noncardia and both intestinal and diffuse gastric cancer were more common in foreign-born than U.S.-born Hispanic men and women, and in those from lower SES, higher enclave neighborhoods. By contrast, among younger and middle-aged Hispanic men, cardia tumors were more common in the U.S.-born than the foreign-born, and in higher SES, lower enclave neighborhoods.

CONCLUSIONS

Varying gastric cancer risk factors among Hispanic subgroups and increasing rates of diffuse gastric cancer in foreign-born Hispanic men and U.S.-born Hispanic women merit further investigation to identify separate disease etiologies.

IMPACT

Age, sex, birthplace, SES, and acculturation modify gastric cancer incidence in Hispanics and should be considered when examining disease risk and prevention.

Nativity and papillary thyroid cancer incidence rates among Hispanic women in California

BACKGROUND

Overall, the incidence of papillary thyroid cancer in Hispanic women residing in the United States (US) is similar to that of non-Hispanic white women. However, little is known as to whether rates in Hispanic women vary by nativity, which may influence exposure to important risk factors.

METHODS

Nativity-specific incidence rates among Hispanic women were calculated for papillary thyroid cancer using data from the California Cancer Registry (CCR) for the period 1988-2004. For the 35% of cases for whom birthplace information was not available from the CCR, nativity was statistically imputed based on age at Social Security number issuance. Population estimates were extracted based on US Census data. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were also estimated.

RESULTS

In young (age <55 years) Hispanic women, the incidence of papillary thyroid cancer among US-born women (10.65 per 100,000) was significantly greater than that for foreign-born women (6.67 per 100,000; IRR, 1.60 [95% CI, 1.44-1.77]). The opposite pattern was observed in older women. The age-specific patterns showed marked differences by nativity: among foreign-born women, rates increased slowly until age 70 years, whereas among US-born women, incidence rates peaked during the reproductive years. Incidence rates increased over the study period in all subgroups.

CONCLUSION

Incidence rates of papillary thyroid cancer vary by nativity and age among Hispanic women residing in California. These patterns can provide insight for future etiologic investigations of modifiable risk factors for this increasingly common and understudied cancer.

Challenges in identifying Native Hawaiians and Pacific Islanders in population-based cancer registries in the U.S

Lack of disaggregated data for Native Hawaiians and Pacific Islanders (NHPIs) in the U.S. has resulted in severe gaps in understanding health disparities and unique health needs of NHPIs. Telephone interviews were conducted with 272 cancer patients identified by a population-based cancer registry. The self-reported NHPIs status was compared with that identified by the registry. Sensitivity, Specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) were calculated. Alternative NHPIs identification methods were explored. The registry had acceptable sensitivity (89%), specificity (96%) and NPV (99%), but low PPV (62%) in identifying NHPIs. Using additional information on surname and birthplace from the registry improved the identification of NHPIs, but either increased the false positive or decreased the counts of true NHPIs cases. Improved data collection methods and practices in identifying NHPIs in population-based cancer registries are needed and caution in interpreting cancer data for NHPIs is warranted.

Lymphoid malignancies in U.S. Asians: incidence rate differences by birthplace and acculturation

BACKGROUND

Malignancies of the lymphoid cells, including non-Hodgkin lymphomas (NHL), HL, and multiple myeloma, occur at much lower rates in Asians than other racial/ethnic groups in the United States. It remains unclear whether these deficits are explained by genetic or environmental factors. To better understand environmental contributions, we examined incidence patterns of lymphoid malignancies among populations characterized by ethnicity, birthplace, and residential neighborhood socioeconomic status (SES) and ethnic enclave status.

METHODS

We obtained data about all Asian patients diagnosed with lymphoid malignancies between 1988 and 2004 from the California Cancer Registry and neighborhood characteristics from U.S. Census data.

RESULTS

Although incidence rates of most lymphoid malignancies were lower among Asian than white populations, only follicular lymphoma (FL), chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), and nodular sclerosis (NS) HL rates were statistically significantly lower among foreign-born than U.S.-born Asians with incidence rate ratios ranging from 0.34 to 0.87. Rates of CLL/SLL and NS HL were also lower among Asian women living in ethnic enclaves or lower SES neighborhoods than those living elsewhere.

CONCLUSIONS

These observations support strong roles of environmental factors in the causation of FL, CLL/SLL, and NS HL.

IMPACT

Studying specific lymphoid malignancies in U.S. Asians may provide valuable insight toward understanding their environmental causes.

The California Neighborhoods Data System: a new resource for examining the impact of neighborhood characteristics on cancer incidence and outcomes in populations

Research on neighborhoods and health has been growing. However, studies have not investigated the association of specific neighborhood measures, including socioeconomic and built environments, with cancer incidence or outcomes. We developed the California Neighborhoods Data System (CNDS), an integrated system of small area-level measures of socioeconomic and built environments for California, which can be readily linked to individual-level geocoded records. The CNDS includes measures such as socioeconomic status, population density, racial residential segregation, ethnic enclaves, distance to hospitals, walkable destinations, and street connectivity. Linking the CNDS to geocoded cancer patient information from the California Cancer Registry, we demonstrate the variability of CNDS measures by neighborhood socioeconomic status and predominant race/ethnicity for the 7,049 California census tracts, as well as by patient race/ethnicity. The CNDS represents an efficient and cost-effective resource for cancer epidemiology and control. It expands our ability to understand the role of neighborhoods with regard to cancer incidence and outcomes. Used in conjunction with cancer registry data, these additional contextual measures enable the type of transdisciplinary, "cells-to-society" research that is now being recognized as necessary for addressing population disparities in cancer incidence and outcomes.

U.S. geographic distribution of prevaccine era cervical cancer screening, incidence, stage, and mortality

BACKGROUND

Cervical cancer prevention programs are being reconfigured to incorporate human papillomavirus (HPV) testing and vaccination. To define priority areas for prevention efforts, we examined the geographic distribution of cervical cancer screening, incidence, stage, and mortality in the United States, prior to the introduction of HPV-based prevention technologies.

METHODS

County-level cervical cancer incidence data from 37 central registries were obtained from Surveillance, Epidemiology, and End Results and North American Association of Central Cancer Registries. A spatial-temporal model that accounted for demographic and behavioral attributes was used to generate a complete view of county-level incidence from 1995 to 2004, including counties with missing data. Distribution of stage at diagnosis was examined by registry. Counties with high mortality and infrequent screening were identified using vital statistics and newly available county-level screening estimates.

RESULTS

Compared with non-Hispanic whites and Asian and Pacific Islanders, incidence rates were higher among non-Hispanic black, American Indian and Alaska Native, and Hispanic women. Counties with infrequent screening often experienced elevated incidence and mortality rates and were located in states with suboptimal stage at diagnosis profiles. Affected areas included Appalachia, the southeastern Atlantic states, and the lower Mississippi Valley. Elevated death rates were experienced in central counties of large metropolitan areas.

CONCLUSIONS

Geographic and racial/ethnic variability were evident in cervical cancer incidence and mortality. Women living in areas with endemic poverty would benefit from access to HPV-based prevention technologies.

IMPACT

These findings provide a baseline for monitoring progress in cervical cancer control in the era of HPV-based prevention.

Quality of cancer care among foreign-born and US-born patients with lung or colorectal cancer

BACKGROUND

Disparities in care have been documented for foreign-born cancer patients in the United States. However, few data are available regarding patients with lung and colorectal cancer. In the current study, the authors assessed whether patient-reported quality and receipt of recommended care differed between US-born and foreign-born cancer patients.

METHODS

The authors collected surveys and medical records for a population-based cohort including white, Hispanic, and Asian adults (2205 US-born and 890 foreign-born individuals) with lung or colorectal cancer diagnosed in California from 2003 through 2005. Logistic regression was used to assess the association between nativity and patient-reported quality of care and receipt of recommended treatments (adjuvant chemotherapy for stage III colon cancer, adjuvant chemotherapy and radiotherapy for stage II/III rectal cancer, and curative surgery for stage I/II nonsmall cell lung cancer). The authors also assessed whether language explained any differences in care by nativity.

RESULTS

Overall, 46% of patients reported excellent care, but foreign-born patients were less likely than US-born patients to report excellent quality of care (adjusted odds ratio [AOR], 0.80; 95% confidence interval [95% CI], 0.65-1.00), a difference partly explained by the language of the survey, an indicator of English proficiency. Rates of recommended therapies ranged from 64% to 85%; foreign-born patients were less likely to receive chemotherapy and radiotherapy for stage II/III rectal cancer (AOR, 0.35; 95% CI, 0.12-0.99). Rates of other treatments did not differ significantly by nativity.

CONCLUSIONS

Foreign-born cancer patients reported lower quality of care and were less likely to receive some cancer therapies than patients born in the Unites States. Better coordination of care and communication regarding cancer treatments and expanded use of interpreters may lessen these disparities.

The influence of nativity and neighborhoods on breast cancer stage at diagnosis and survival among California Hispanic women

BACKGROUND

In the US, foreign-born Hispanics tend to live in socioeconomic conditions typically associated with later stage of breast cancer diagnosis, yet they have lower breast cancer mortality rates than their US-born counterparts. We evaluated the impact of nativity (US- versus foreign-born), neighborhood socioeconomic status (SES) and Hispanic enclave (neighborhoods with high proportions of Hispanics or Hispanic immigrants) on breast cancer stage at diagnosis and survival among Hispanics.

METHODS

We studied 37,695 Hispanic women diagnosed from 1988 to 2005 with invasive breast cancer from the California Cancer Registry. Nativity was based on registry data or, if missing, imputed from case Social Security number. Neighborhood variables were developed from Census data. Stage at diagnosis was analyzed with logistic regression, and survival, based on vital status determined through 2007, was analyzed with Cox proportional hazards regression.

RESULTS

Compared to US-born Hispanics, foreign-born Hispanics were more likely to be diagnosed at an advanced stage of breast cancer (adjusted odds ratio (OR) = 1.14, 95% confidence interval (CI): 1.09-1.20), but they had a somewhat lower risk of breast cancer specific death (adjusted hazard ratio (HR) = 0.94, 95% CI: 0.90-0.99). Living in low SES and high enclave neighborhoods was associated with advanced stage of diagnosis, while living in a lower SES neighborhood, but not Hispanic enclave, was associated with worse survival.

CONCLUSION

Identifying the modifiable factors that facilitate this survival advantage in Hispanic immigrants could help to inform specific interventions to improve survival in this growing population.

Disparities in liver cancer incidence by nativity, acculturation, and socioeconomic status in California Hispanics and Asians

BACKGROUND

Asians and Hispanics have the highest incidence rates of liver cancer in the United States, but little is known about how incidence patterns in these largely immigrant populations vary by nativity, acculturation, and socioeconomic status (SES). Such variations can identify high-priority subgroups for prevention and monitoring.

METHODS

Incidence rates and rate ratios (IRR) by nativity among 5,400 Hispanics and 5,809 Asians diagnosed with liver cancer in 1988-2004 were calculated in the California Cancer Registry. Neighborhood ethnic enclave status and SES were classified using 2000 U.S. Census data for cases diagnosed in 1998-2002.

RESULTS

Foreign-born Hispanic males had significantly lower liver cancer incidence rates than U.S.-born Hispanic males in 1988-2004 (e.g., IRR = 0.54, 95% confidence interval [CI] = 0.50-0.59 in 1997-2004), whereas foreign-born Hispanic females had significantly higher rates in 1988-1996 (IRR = 1.42, 95% CI = 1.18-1.71), but not 1997-2004. Foreign-born Asian males and females had up to 5-fold higher rates than the U.S.-born. Among Hispanic females, incidence rates were elevated by 21% in higher-enclave versus lower-enclave neighborhoods, and by 24% in lower- versus higher-SES neighborhoods. Among Asian males, incidence rates were elevated by 23% in higher-enclave neighborhoods and by 21% in lower-SES neighborhoods. In both racial/ethnic populations, males and females in higher-enclave, lower-SES neighborhoods had higher incidence rates.

CONCLUSIONS

Nativity, residential enclave status, and neighborhood SES characterize Hispanics and Asians with significantly unequal incidence rates of liver cancer, implicating behavioral or environmental risk factors and revealing opportunities for prevention.

IMPACT

Liver cancer control efforts should especially target foreign-born Asians, U.S.-born Hispanic men, and residents of lower-SES ethnic enclaves.

Breast cancer incidence patterns among California Hispanic women: differences by nativity and residence in an enclave

BACKGROUND

Breast cancer incidence is higher in U.S.-born Hispanic women than foreign-born Hispanics, but no studies have examined how these rates have changed over time. To better inform cancer control efforts, we examined incidence trends by nativity and incidence patterns by neighborhood socioeconomic status (SES) and Hispanic enclave (neighborhoods with high proportions of Hispanics or Hispanic immigrants).

METHODS

Information about all Hispanic women diagnosed with invasive breast cancer between 1988 and 2004 was obtained from the California Cancer Registry. Nativity was imputed from Social Security number for the 27% of cases with missing birthplace information. Neighborhood variables were developed from Census data.

RESULTS

From 1988 to 2004, incidence rates for U.S.-born Hispanics were parallel but lower than those of non-Hispanic whites, showing an annual 6% decline from 2002 to 2004. Foreign-born Hispanics had an annual 4% increase in incidence rates from 1995 to 1998 and a 1.4% decline thereafter. Rates were 38% higher for U.S.- than foreign-born Hispanics, with elevations more pronounced for localized than regional/distant disease, and for women>50 years of age. Residence in higher SES and lower Hispanic enclave neighborhoods were independently associated with higher incidence, with Hispanic enclave having a stronger association than SES.

CONCLUSIONS

Compared with foreign-born, U.S.-born Hispanic women in California had higher prevalence of breast cancer risk factors, suggesting that incidence patterns largely reflect these differences in risk factors.

IMPACT

Further research is needed to separate the effects of individual- and neighborhood-level factors that affect incidence in this large and growing population.

Influence of birthplace on breast cancer diagnosis and treatment for Hispanic women

Research has shown that Hispanic women in the United States are diagnosed with breast cancer at more advanced stages and initiate treatment later than non-Hispanic white women. We investigated whether stage at breast cancer diagnosis and receipt of primary therapy differ by ethnicity and birthplace among US-born Hispanic, foreign-born Hispanic, and white women. We studied 31,012 Hispanic women and 372,313 white women with a first diagnosis of invasive breast cancer during 1988 and 2005 living in a SEER area. We used multinomial logistic regression to assess the association of ethnicity and birthplace with stage at diagnosis and, among women with stage I or II cancers, primary therapy [mastectomy, breast-conserving surgery (BCS) with radiation, BCS without radiation], adjusting for other patient and tumor characteristics. Rates of stage at diagnosis differed significantly by race/ethnicity and birthplace (P < 0.001). Foreign-born Hispanics had lower adjusted rates of stage I breast cancer at diagnosis (35.4%) than US-born Hispanics (40.6%), birthplace-unknown Hispanics (42.3%), and whites (47.4%). Receipt of primary therapy also differed significantly by race/ethnicity and birthplace (P < 0.001). Foreign-born Hispanics and birthplace-unknown Hispanics had lower rates of BCS with radiation (34.9%, 30.7%) than US-born Hispanics (41.5%) and whites (38.8%). Foreign-born Hispanic women in the United States have a lower probability of being diagnosed at earlier stages of breast cancer and, for women with early-stage disease, of receiving radiation following BCS compared to US-born Hispanics and whites. Identifying factors mediating these disparities may help in developing culturally and linguistically appropriate interventions and improving outcomes.

Racial/ethnic variation in EBV-positive classical Hodgkin lymphoma in California populations

Epstein-Barr virus (EBV) is detected in the tumor cells of some but not all Hodgkin lymphoma (HL) patients, and evidence indicates that EBV-positive and -negative HL are distinct entities. Racial/ethnic variation in EBV-positive HL in international comparisons suggests etiologic roles for environmental and genetic factors, but these studies used clinical series and evaluated EBV presence by differing protocols. Therefore, we evaluated EBV presence in the tumors of a large (n = 1,032), racially and sociodemographically diverse series of California incident classical HL cases with uniform pathology re-review and EBV detection methods. Tumor EBV-positivity was associated with Hispanic and Asian/Pacific Islander (API) but not black race/ethnicity, irrespective of demographic and clinical factors. Complex race-specific associations were observed between EBV-positive HL and age, sex, histology, stage, neighborhood socioeconomic status (SES), and birth place. In Hispanics, EBV-positive HL was associated not only with young and older age, male sex, and mixed cellularity histology, but also with foreign birth and lower SES in females, suggesting immune function responses to correlates of early childhood experience and later environmental exposures, respectively, as well as of pregnancy. For APIs, a lack of association with birth place may reflect the higher SES of API than Hispanic immigrants. In blacks, EBV-positive HL was associated with later-stage disease, consistent with racial/ethnic variation in certain cytokine polymorphisms. The racial/ethnic variation in our findings suggests that EBV-positive HL results from an intricate interplay of early- and later-life environmental, hormonal, and genetic factors leading to depressed immune function and poorly controlled EBV infection.

Identifying newly diagnosed Hispanic cancer patients who use a physician with a Spanish-language practice, for studies of quality of cancer treatment

BACKGROUND

Language barriers may affect cancer treatment choices among U.S. Hispanic-Latino patients newly diagnosed with cancer. This study examined use of a physician with a Spanish-language practice (SLP) by Hispanic patients diagnosed with a cancer reported to a population-based cancer registry.

METHODS

Data on all 1,874 Connecticut Hispanic patients diagnosed with cancer in 1999-2002 were obtained from the Connecticut Tumor Registry, including the follow-up physician (FUP) responsible for the patient's medical care around the time of cancer diagnosis. FUPs were compared to a list of Spanish surnames (SS) to identify potential Hispanic ethnicity. A statewide database from a survey of licensed physicians was used to identify SLPs. For the two most common cancers (breast and prostate), SLP was examined in relation to radiotherapy after breast-conserving surgery (202 patients) and for prostate cancer (207 patients).

RESULTS

The 1,874 patients had 829 different FUPs, of whom 783 had information on SLP; only 37 FUPs had a SS but 269 had a SLP. Of the 1,727 Hispanic patients with known FUP, only 3.5% had a SS FUP, while 36.8% had a FUP with a SLP. Having a FUP with a SLP was statistically significantly associated with receipt of radiotherapy for breast cancer but not for prostate cancer.

CONCLUSION

This methodology should be explored in states with larger Hispanic populations, and future efforts should include efforts to obtain data on other cancer treatments (e.g., chemotherapy and hormone therapy).