Comparing Cancer Mortality Rates Among US and Foreign-Born Persons: United States,

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1 National Center for Chronic Disease Prevention and Health Promotion Comparing Cancer Mortality Rates Among US and Foreign-Born Persons: United States, Benjamin D. Hallowell, PhD, MPH NAACCR 2018 Annual Conference June 14, 2018

2 Acknowledgements Coauthors Division of Cancer Prevention and Control (DCPC) Mona Saraiya Virginia Senkomago Meheret Endeshaw Hilda Razzaghi Emory University Matthew McKenna 2

3 Rise in Foreign-Born Population 9.6 Million 40.0 Million ~12.9% of the general population US Census Bureau,

4 Where Are People Immigrating From? S Census Bureau,

5 S Census Bureau,

6 S Census Bureau,

7 Immigrants and Health Insurance Purchase health insurance via Marketplace: Lawfully present in the US Medicaid, Medicare, and CHIP: Lawfully present in the US and have lived constantly in the US for at least 5 years 7

8 Immigrant Paradox Barriers to care: limited English proficiency, lack of health insurance, lower educational attainment, and lower SES Immigrants are healthier, and have longer life expectancy when compared to the US-born population Lower rates of: hypertension, asthma, high cholesterol, obesity, smoking, mental health disorders Why is this the case? Migration selectivity Social support Risk factors ingh & Hiatt, 2006; Dominguez et al.,

9 Foreign-Born Population and Cancer Overall, foreign-born individuals have lower cancer mortality rates when compared to the US-born population Elevated risk of mortality from infection related cancers Liver, stomach, cervical Foreign-born individuals have lower rates cancer screening for cervical, breast, and colorectal cancer ingh & Hiatt, 2006; Singh & Miller

10 The Problem Unfortunately, the rapid rise in the foreign-born population has not been accompanied by a rise in immigrant health research Are cancer mortality rates still lower? Have the rates changed over time? Increased risk for infection-related cancers? ingh & Hiatt,

11 Study Objective Use the most recent cancer mortality data to: Describe cancer mortality risk among the foreign-born population Determine if any specific subgroups of the population have elevated risk Identify specific cancers for which foreign-born individuals may be at increased risk 11

12 Methods Numerator: Population-based cancer mortality data CDC s National Center for Health Statistics Sex, race, ethnicity, birth place, age at death, state of residence, and cause of death >99% of all deaths in 50 States and the District of Columbia that occurred between Outcome: Malignant Cancers (ICD-10: C00-C97) Denominator: Population Estimates US Census Bureau s American Community Survey (ACS) Provides 1-year estimates of the US population nativity status Estimated population by birth place, age, race, sex, and census region 12

13 Methods Nativity Status US-Born: 50 States, District of Columbia, or US territories Foreign-Born: all individuals with other place of birth recorded 13

14 Methods Statistical Analysis Formatted mortality data and population estimates in SEER*Prep to create SEER*STAT databases. Calculated age-adjusted mortality rates and rate ratios, and stratified by birth place, sex, age, and race/ethnicity 14

15 Results 210 Cancer Morality Rate, by Nativity Status 5,670,535 cancer deaths 528,694 ~ 9.3% occurred among foreign-born individuals Foreign-born individuals had a 31% lower risk of cancer Rate per 100,000 people US-born Foreign-born mortality 52.5 Rate Ratio: 0.69 (0.68, 0.69) US-born Foreign-born 15

16 Cancer Mortality Rates, by Sex and Nativity Status 260 Rate per 100,000 people Males RR: 0.68* Females RR: 0.70* Male US-born Male Foreign-born Female US-born Female Foreign-born *p<

17 Cancer Mortality Rates by Race/Ethnicity: United States White Black Asian/Pacific Islander US-Born Hispanic Rate (per 100,000) US-Born Foreign-Born Foreign-Born Average Cancer Mortality Rate US-Born Foreign-Born US-Born Foreign-Born 0 White 17

18 Foreign-Born and Elevated Cancer Mortality Risk Cancer Site Deaths Rate Ratio Associated Infection Nasopharynx 1, Epstein-Barr Virus Kaposi Sarcoma HHV-8 Stomach 24, H. pylori Gallbladder 3, Liver Fluke Acute Lymphocytic Leukemia* 2, Liver and Intrahepatic Bile Duct 31, HBV, HCV *High Thyroid* Survival Rates 2,

19 12 Liver Cancer Mortality Rates by Race/Ethnicity: United States White Black Asian/Pacific Islander Hispanic 9 Rate (per 100,000) White 19

20 Stomach Cancer Mortality Rates by Race/Ethnicity: United States White Black Asian/Pacific Islander Hispanic 6 Rate (per 100,000) White 20

21 Foreign-Born and Preventable Cancers Breast 1 Rate Ratio Cervical 1 Rate Ratio Colorectal Rate Ratio Lung Rate Ratio Overall 0.70* 0.95* 0.75* 0.49* Whites Blacks Asian/Pacific Islander Hispanics 1Calculated only among women. *p<

22 Foreign-Born and Preventable Cancers Breast 1 Rate Ratio Cervical 1 Rate Ratio Colorectal Rate Ratio Lung Rate Ratio Overall 0.70* 0.95* 0.75* 0.49* Whites 0.96* 0.90* 0.97* 0.63* Blacks 0.63* 0.81* 0.55* 0.25* Asian/Pacific Islander 0.65* * 0.80* Hispanics 0.84* * 0.81* 1Calculated only among women. *p<

23 Conclusions Overall, foreign-born individuals have a lower risk of cancer mortality when compared to US-born individuals Rates vary widely race/ethnicity For select infection-related cancers, cancer mortality rates among the foreign-born population remain elevated Among screenable cancers, lower mortality risk is observed among foreign-born, despite lower access to healthcare and lower screening rates 23

24 Strengths & Limitations Strengths Able to analyze mortality data from the entire US Population estimates Limitations Data obtained from death certificates Misclassification of race/ethnicity Residency duration 24

25 Public Health Implications Continued prevention, screening, and treatment for cancer causing infections among foreign-born individuals Promote programs and policies that link immigrants with care, insurance, and health care services Despite lower rates, we should work to improve access and availability of cancer screening programs to the foreign-born population 25

26 For more information, contact CDC CDC-INFO ( ) TTY: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

27 Additional Slides

28 Foreign-Born and Lawful Status

29 Immigrant Paradox Potential Barriers to Care Foreign-Born US-Born Limited English proficiency 49.7% 1.8% Lack of health insurance 37.7% 17.3% Education level (<high school) 30.3% 10.1% Below the poverty line 18.7% 15.4% Singh & Hiatt, 2006; Dominguez et al., 2015

30 Monitoring Challenges Salmon bias Status rarely recorded Denominator estimates difficult Lack of residency duration information

31 State or Country of Birth Options 50 States District of Columbia Puerto Rico Virgin Islands Guam Canada Cuba Mexico Remainder of world