Scarlett Gomez, MPH, PhD Cancer Prevention Institute of California NAACCR 2017 conference, Albuquerque NM June 2017

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1 The influence of socioeconomic status and ethnic enclave on endometrial cancer mortality among Hispanic and Asian American/Pacific Islander women in California Scarlett Gomez, MPH, PhD Cancer Prevention Institute of California NAACCR 2017 conference, Albuquerque NM June 2017

2 Study authors Renata Abrahao, PhD Debbie Goldberg, MS Veronica (Wendy) Setiawan, PhD Scarlett Lin Gomez, PhD Iona Cheng, PhD

3 Background Endometrial cancer (EC) is the most common gynecologic cancer diagnosed in women in developed countries In the US, approximately 61,380 new cases of EC and 10,920 deaths from the disease are expected to occur in 2017

4 Background The incidence rates have been increasing in the US, particularly for the most aggressive histologic subtypes In addition, EC is one of the few cancers for which mortality rates are increasing rather than decreasing (AAPC= 1.2% from 2004 to 2013)

5 Background Racial/ethnic disparities in EC mortality are well known with NH blacks having significantly higher mortality than NH whites However, there are controversies on whether mortality risk differs among Hispanic and AAPI women compared with NH white women California has the largest Hispanic and AAPI populations in the US

6 Background Social factors have been shown to independently impact cancer survival of patients of different races/ethnicities To our knowledge, no previous study has examined the influence of neighborhood factors including SES and ethnic enclave on EC outcomes among Hispanics and AAPIs in the US

7 Study Aim Investigate the influence of nses and ethnic enclave on the mortality risk of EC among Hispanic and AAPI women in California, controlling for clinical and sociodemographic variables

8 Methods Study design: population-based cohort Period of diagnosis: , follow-up through December 2014 Age at diagnosis: 40 years Statistical analyses: Cox PH models to estimate the hazard of death from EC (overall and cancer-specific mortality)

9 Variables available in the CCR dataset Patient Tumor Clinical Others Age at diagnosis Diagnostic confirmation Chemotherapy Date of birth Neighborhood SES Grade Radiotherapy Date of diagnosis Ethnic enclave Histologic subtype Surgery Date of last vital status Race/ethnicity Stage at Treatment facility diagnosis Marital status Behavior Health insurance (from 1996) Patient ID Tumor ID Calendar period Vital status Cause of death

10 Results N= 15,245 women: 9,367 Hispanics and 5,878 AAPIs Mean age of diagnosis was about 60 years 69% diagnosed with localized disease Endometrioid endometrial carcinoma was the most common histologic subtype

11 Results The majority (75%) of Hispanic women resided in the lower SES neighborhoods In contrast, about 52% of AAPI women resided in higher SES neighborhoods The majority of EC patients lived in highest ethnic enclaves (63% Hispanics and 75% AAPIs)

12 Hazard ratios of death Neighborhood SES All-cause mortality HR (95%) EC-specific mortality HR (95%) Hispanics AAPI Hispanics AAPI Q5: Highest Reference Reference Q (0.96, 1.29) 1.11 (0.86, 1.43) Q (0.98, 1.31) 1.20 (0.93, 1.54) Q (1.10, 1.48) 1.34 (1.03, 1.73) Q1: Lowest 1.39 (1.20, 1.62) 1.41 (1.09, 1.83) Ethnic enclave More ethnic Reference Reference Less ethnic 1.01 (0.92, 1.11) 0.89 (0.76, 1.04) Multivariable models included variables significant at P < 0.05 in unadjusted model: grade, histology, treatment (surgery and adjuvant chemotherapy), calendar period of diagnosis, age at diagnosis, marital status, NCI designated cancer center, nses, and ethnic enclave.

Hazard ratios of death Neighborhood SES All-cause mortality HR (95%) EC-specific mortality HR (95%) Hispanics AAPI Hispanics AAPI Q5: Highest Reference Reference Reference Reference Q4 1.11 (0.96, 1.

13 Hazard ratios of death Neighborhood SES All-cause mortality HR (95%) EC-specific mortality HR (95%) Hispanics AAPI Hispanics AAPI Q5: Highest Reference Reference Reference Reference Q (0.96, 1.29) 1.20 (1.03, 1.39) 1.11 (0.86, 1.43) 1.13 (0.90, 1.42) Q (0.98, 1.31) 1.23 (1.05, 1.43) 1.20 (0.93, 1.54) 0.94 (0.74, 1.20) Q (1.10, 1.48) 1.24 (1.06, 1.45) 1.34 (1.03, 1.73) 0.96 (0.74, 1.23) Q1: Lowest 1.39 (1.20, 1.62) 1.34 (1.12, 1.60) 1.41 (1.09, 1.83) 1.21 (0.92, 1.59) Ethnic enclave More ethnic Reference Reference Reference Reference Less ethnic 1.01 (0.92, 1.11) 0.92 (0.81, 1.03) 0.89 (0.76, 1.04) 0.90 (0.75, 1.08) Multivariable models included variables significant at P < 0.05 in unadjusted model: grade, histology, treatment (surgery and adjuvant chemotherapy), calendar period of diagnosis, age at diagnosis, marital status, NCI designated cancer center, nses, and ethnic enclave.

14 Conclusions Lower nses was independently associated with 30-40% higher risk of death among Hispanic and AAPI women with EC Ethnic enclave was not significantly associated with EC mortality risk, but suggestion of worse EC-specific survival in more ethnic neighborhoods What about immigration status?

15 Thank you!

Cancer Prevention Institute of California, Fremont, California. 2. Stanford Cancer Institute, Stanford, California. 3

Cancer Prevention Institute of California, Fremont, California. 2. Stanford Cancer Institute, Stanford, California. 3 How much of the racial/ethnic disparities in cancer survival in California is explained by differences in tumor, sociodemographic, institutional and neighborhood characteristics? Elizabeth Ellis 1,2, Alison