National Landmark Reports Highlighting Cancer Disparities Problem Pre - 1980 1986 1989 1996 1999 2001 2002 2003
5 Leading Causes of Death, U.S., 2003, Female 1 2 3 4 5 All races Cardiovascular Cancer Cerebrovascular Chronic lower respiratory Alzheimer s White Cardiovascular Cancer Cerebrovascular Chronic lower respiratory Alzheimer s Black Cardiovascular Cancer Cerebrovascular Diabetes Nephritis American Indian Cardiovascular Cancer Accidents Diabetes Cerebrovascular Asian or Pacific Islander Cancer Heart Cerebrovascular Accidents Diabetes Hispanic Cardiovascular Cancer Cerebrovascular Diabetes Accidents White, non- Hispanic Black, non- Hispanic Cardiovascular Cardiovascular Cancer Cancer Cerebrovascular Cerebrovascular Chronic lower respiratory Diabetes Alzheimer s Nephritis Heron, M. P., & Smith, B. L. (2007). Deaths: Leading causes for 2003 (No. DHHS Kagawa-Singer Publication - Women (PHS) 2007- and 1120): National Center for Health Statistics.
Disease always occurs within a context of human circumstances, including economic status, social position, culture and environment.
Ecological Model of Health * Modified from McElroy and Townsend, 1996.
Culture Environment Economy Technology Religion/World View Language Social Structure Beliefs and Values
Poverty and gender should NOT be an offense which is punishable by death. Harold Freeman, M.D., 2006
California Demographics 2000 >36 million 30% 1% 49% 12% 8% Whites (excluding Hispanics) Asian or Pacific Islander American Indian, Eskimo, or Aleut Blacks Latino
Three Major Questions What populations have poor survival? What are the causes of disparities in survival? How can we eliminate disparities?
Three Major Answers Biases in our society due to: Racism Sexism Ageism
California Hispanic Age 35+ Heart Disease Rate CDC 6/9/ 05 www\\\apps.ncd.cdc.gov
Kian and Remee Horder
California Age 35+ Heart Disease Rates by Ethnicity v. U.S. CDC 6/9/ 05 www\\\apps.ncd.cdc.gov Race/Ethnicity Population Heart Disease - Rate Total Pop 12,576,455 504 536 AI/AN 105,340 243 363 AAPI 1,899,429 315 302 Blacks 1,023,564 678 662 Hispanics 3,450,272 339 348 WHITES 9,548.122 503 529
http://www.cdc.gov/nccdphp/overview.htm Age-Adjusted Death Rates for Diseases of the Heart* Among Women, by Race/Ethnicity,1996 1998 Average annual deaths per 100,000 women, age adjusted to 1940 U.S. standard population, International Classification of Diseases, 9th Rev., codes 390 398, 402, and 404 429. Source: Journal of Women s Health and Gender-Based Medicine, Vol. 10, No. 8, 2001. pp. 717 24.
Major Causes of Death in the U.S. Women have higher rates than Men for CVD and Diabetes *All data are age adjusted to 2000 total U.S. population. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993; 270:2207 12.
Underlying Causes of Most Chronic Diseases 35% -65% Lifestyle choices *All data are age adjusted to 2000 total U.S. population. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993; Kagawa-Singer 270:2207 12. - Women and
Smoking Rates Among Ethnic Populations and Gender Native American (40.8%). Caucasian American (23.1%). African American (20.8%). Among Youth 12-17 Males: 19.1% Females 20.7% Hispanic American (12.3%). Asian/Pacific Islanders (7.1%). www.drugabusestatistics.samhsa.gov/nhsda/nhsda9 7/nhsda983.htm#E10E29
Cancer Incidence Trends California, 1988-2001 700 Rate per 100,000 600 500 400 300 200 100 Asian/Pacific Islander Hispanic Black Non-Hispanic White 0 1988 1990 1992 1994 1996 1998 2000 S. Minority Kwong, Health 2004-3 Nov 2008
Female Breast Cancer Trends California, 1988-2001 140 120 100 80 60 40 20 Rate per 100,000 Chinese Filipino Japanese Korean South Asian Vietnamese S. Kwong, 2004 0 1988 1990 1992 1994 1996 1998 2000
Ethnic Minorities in the U.S. Behavior is influenced by: Cultural Beliefs Minority Status
Relationship with Husbands of Chinese-, Japanese- & European-American Breast Cancer Survivors Theme 2: Nature of marital relationship A. Mutual emotional give and take B. Harmony and Intimacy C. Communication D. Role expectations Same for the 3 groups Harmony rather than intimacy predominates Non-Verbal Inshin denshin in Japanese and Zhih Yi in Chinese Wife s role clearly differentiated as emotional nurturer and husband as source of security Intimacy predominates v. harmony Direct and verbal communication is valued Ability to be dependent on husband Kagawa-Singer and Wellisch, 2002 Psycho-Oncology
Relationship with Husbands of Chinese-, Japanese- & European-American Breast Cancer Survivors Theme 3: Sources of dissonance: Meeting needs A. Empathy Expectations of wives not met by husbands B. Recognition of individuality C. Perceived types of support from H D. Sources of support for W Invalidation of individuality cut a little slack but abandoned to own resources No time out from ongoing stress in relationship Pragmatic problem-solving assistance and tangible aid driving, housecleaning, also reassurance and calm Friends/coworkers (3) Daughters/ Family (husband) (6) Husbands (15) Kagawa-Singer and Wellisch, 2002 Psycho-Oncology
Comparison of Physician Discussion, Decision-making and Disclosure at End of Life after adjustment * Odds Ratio (95% Confidence interval) Japanesespeaking Japanese Americans Englishspeaking Japanese Americans Japanese living in Japan Discuss end-of-life with a physician 0.73 (0.41, 1.31) 1.10 (0.62, 1.94) 1.0 Group decision-making model 1.11 (0.70, 1.74) 0.63 (0.41, 0.97) 1.0 Terminal prognosis disclosure to the patient using words 8.79 (5.42, 14.3) 2.80 (1.79, 4.37) 1.0 Terminal prognosis disclosure to the family using words 2.01 (1.05, 3.88) 1.03 (0.58, 1.83) 1.0 Matsumura, et al. 2000
PATH For Women Survivors and THRIVERS!!
Leading Causes of Death for Asian Males and Females, California, 1997-2001 1 2 3 4 5 Male Cancer Heart Disease Cerebrovascular Disease Chronic Lower Respiratory Disease Accidents Female Cancer Heart Disease Cerebrovascular Disease Influenza & Pneumonia Diabetes
Five Most Frequently Diagnosed Cancers Among Asian/Pacific Islanders, 1997-2001 Rank 1 2 3 4 Male Prostate Lung & Bronchus Colon & Rectum Liver Female Breast Colon & Rectum Lung & Bronchus Uterus 5 Stomach Thyroid
1999-2001 Top 5 Cancer Sites Ethnicity API API Asian Ind Asian Ind Chinese Chinese Filipino Filipino Gender Male Female Male Female Male Female Male Female 1 Lung* Lung* Lung* Breast Lung* Lung* Lung* Lung 2 Colorectum Breast Prostate Lung* Liver* Colorectum Prostate Breast 3 Liver* Colorectum Pancreas Colorectum Colorectum Breast Colorectum Colorectum 4 Prostate Pancreas Leukemia Ovary Stomach Stomach Liver* Pancreas 5 Stomach Stomach Liver* Pancreas Prostate Liver* Non-Hodgkin Ovary Ethnicity Japanese Japanese Korean Korean Vietnamese Vietnamese Gender Male Female Male Female Male Female 1 Lung* Lung* Lung* Lung* Lung* Lung* 2 Colorectum Breast Stomach Stomach Liver* Liver* 3 Stomach Colorectum Liver* Liver* Stomach Colorectum 4 Prostate Pancreas Colorectum Colorectum Colorectum Breast 5 Pancreas Stomach Pancreas Pancreas Leukemia Stomach Ethnicity Nat. Hawai Nat. Hawai Samoan Samoan White White Gender Male Female Male Female Male Female 1 2 3 Lung* Colorectum Prostate Lung* Breast Pancreas Lung* Stomach Colorectum Lung* Breast Stomach Lung* Prostate Colorectum Lung* Breast Colorectum Chu, 2004 4 5 Stomach Pancreas Colorectum Stomach Liver* Prostate Ovary Endomet. Pancreas Non-Hodgkin Ovary Pancreas
Age-Adjusted Death Rates Due to All Causes, California 1990 1200 1000 800 600 400 200 0 White Black Native American Mexican Puerto Rican Cuban Other Hispanic Chinese Japanese Korean Vietnamese Cambodian Thai Laotian Filipino Asian Indian Other Asian Hawaiian Guamanian Samoan Other Islander
Five Cancers contributing to overall cancer incidence burden in males by race/ethnicity and geography Chinese Males Percent of All Cancers 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Colon (5) Esophagus (6) Liver (12) Stomach (20) Lung (26) Stomach (7) Colon (8) Nasopharynx (9) Liver (11) Lung (24) Rectum (5) Liver (8) Colon (10) Prostate (16) Lung (18) China Hong Kong/ Singapore Geographic Region US Chinese
1999 Poverty Status in Asian Americans 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 12.38% 17.69% 12.60% 9.75% 29.28% 13.50% 6.25% 37.78% 9.72% 14.77% 18.50% 16.46% 14.35% 16.05% US Total NHOPI Asian Alone Asian Indian Cambodian Chinese Filipino Hmong Japanese Korean Laotian Pakistani Thai Percentage Below Poverty Vietnamese Source: Census 2000 Population
Prostate Cancer Five-Year Average Annual Age-Adjusted Incidence Rates per 100,000, California, 1997-2001 120 Rate per 100,000 S. Kwong, 2004 109.9 100 99.5 87.1 80 72.1 60 53.6 40 41.6 20 0 Chinese Filipino Japanese Korean South Kagawa-Singer Asian Vietnamese - Women and
Lung and Bronchus Cancer Five-Year Average Annual Age-Adjusted Mortality Rates per 100,000, California, 1997-2001 60 Rate per 100,000 Male Female 55.3 S. Kwong, 2004 50 46.1 45.8 46.6 40 40.1 30 20 24.8 17.0 20.9 20.8 21.1 10 12.1 4.7 0 Chinese Filipino Japanese Korean South Kagawa-Singer Asian Vietnamese - Women and
20.0 Differences between 1988-92 and 1999-2001Cancer Mortality Rates 10.0 0.0-10.0-20.0-30.0-40.0 White Total API Chinese Filipino Japanese Nat. Haw. AI/AN Hispanic Chu, K. 2004