homework - English
January 2017 Abstracts S309
OA17.02
Potential Health and Economic
Consequences of Organized vs
Opportunistic Lung Cancer Screening in
Canada
William Evans,1 Cindy Gauvreau,2 Saima Memon,2
John Goffin,3 Jason Lacombe,2 Michael Wolfson,4
Natalie Fitzgerald,2 Anthony Miller5 1Cancer Care
Ontario, Toronto/ON/Canada, 2Canadian Partnership
Against Cancer, Toronto/ON/Canada, 3Oncology,
Juravinski Cancer Centre, Hamilton/ON/Canada,
4Populemics, University of Ottawa, Ottawa/ON/Canada,
5Public Health, University of Toronto, Toronto/ON/
Canada
Background: Annual LDCT screening for individuals 55-
74 yrs with >30 pack-year smoking history is supported
by evidence from the NLST but has led to questions of
implementation. Compared to organized screening
(ORG), opportunistic screening (OPP) may utilize
broader entry criteria and not include smoking
cessation.
Methods: Health and economic impacts of ORG using
NLST entry criteria were modelled using population
microsimulation (OncSim e formerly Canadian Risk
Management Model v 2.3) and compared to OPP sce-
narios. We modeled ORG at a participation rate of 30 and
60\%, with and without smoking cessation, compared to
various plausible OPP scenarios: younger individuals
(40-74 yrs); lesser smoking histories (10 or 20 pack-
yrs). Outcomes projected to 20 years included incidence,
mortality, number of scans, invasive diagnostics for false
positives, and screening and treatment costs. A lifetime
horizon and 3\% discounting were used to estimate the
incremental cost-effectiveness ratio (ICER) from a health
system perspective. All costs are in 2016 CAD.
Results: A large number of outputs can be presented. At
a participation rate of 30\%, average annual incremental
incident cases of lung cancer with OPP for 40-74 yr-olds
with 10 pack-yr histories are higher by 254 over ORG
without cessation, and there would be an average 135
fewer deaths annually. However, the annual number of
CT scans would increase by 433,000 on average and
diagnostic tests for false positive results would increase
by 1540. Average annual costs would increase by $141
M compared with ORG without cessation, resulting in an
ICER of $133,000/QALY. OPP with 40-74 yr-olds having
20 and 30 pk-yr histories result in $92,147 and 74,978/
QALY respectively. In all cases of OPP compared to ORG
with cessation there are net losses of QALY. Notably,
ORG with smoking cessation compared to ORG without
yields an ICER of $2800/QALY.
Conclusion: OPP screening results in more incident
cases and fewer deaths but more cost from over-diag-
nosis and false positives. In Canada, an annual screening
program with strict adherence to NLST entry criteria
could be highly cost-effective. Jurisdictions will have to
weigh the benefits and risks of LDCT scanning beyond
the currently available evidence.
Keywords: screening, organized, opportunistic, cost
OA17.03
Insurance Type Influences Stage,
Treatment, and Survival in Asian
American Lung Cancer Patients
Apichat Tantraworasin,1 Emanuela Taioli,2
Bian Liu,2 Andrew Kaufman,1 Raja Flores1 1Thoracic
Surgery, ICAHN Medical School at Mount Sinai, New York/
NY/United States of America, 2Population Health Science
and Policy, ICAHN School of Medicine at Mount Sinai, New
York/United States of America
Background: Effect of insurance type on lung cancer
diagnosis, treatment and survival is still under debate in
Asian patients living in United States.
Methods: A total of 447,167 patients (18 to 113 years),
diagnosed with lung cancer between 2004 and 2013 in
the Surveillance, Epidemiology, and End Results data-
base were analyzed. Patient demographics and clinical
characteristics were compared between Asian and Non-
Asian patients. In Asian patients, patient demographics
and characteristics were compared among insurance
types. Multivariable logistic regression analysis was
performed to identify the effect of insurance types on
stage at diagnosis and treatment modalities. Multivar-
iable cox’s regression analysis was performed to iden-
tify the effect of insurance type on cancer-specific
death.
Results: Asian were significantly more frequently males
(56.7\% vs. 53.1\%), married (62.2\% vs. 50.2\%), with
Medicaid (17.4\% vs. 8.7\%), living in rural area (93.6\% vs.
86.9\%), in a low income county (26.3\% vs. 13.4\%), and
stage 4 at time of diagnosis (51.1\% vs. 48.0\%) than non-
Asian patients (all p-value < 0.001). Among 26,884 Asian
lung cancer patients, uninsured were significant younger
(61.1±10.8 years) than non-Medicaid (69.1±11.9 years)
and Medicaid (70.7±11.7 years), p <0.001, more likely
single (18.9 \% vs. 8.8\% vs. 13.0\%); living in a high income
county (41.8\% vs. 30.5\% vs. 38.6\%); more likely to be
stage IV (63.7\% vs. 50.0\% vs. 51.2\%); and not undergo
surgery (86.2\% vs. 75.4\% vs. 82.6\%), [all p-value <
0.001). Localized disease was more frequent in non-
Medicaid (21.2\%) and Medicaid (17.3\%) compared to
http://crossmark.crossref.org/dialog/?doi=10.1016/j.jtho.2016.11.326&domain=pdf
S310 Journal of Thoracic Oncology Vol. 12 No. 1S
uninsured (9.0), (p < 0.001). At multivariable analyses,
insurance type was not associated with cancer-directed
surgery and radiotherapy. Insurance was significantly
associated with cancer-specific death (uninsured HR 1.37
95\%CI 1.07-1.75; non-Medicaid HR 1.17 95\% CI 1.07-
1.28 vs Medicaid).
Conclusion: Insurance type affects stage at diagnosis
and cancer-specific death but not surgical treatment and
radiotherapy in Asian lung cancer patients.
Keywords: Disparities, race, cancer-specific death,
insurance
OA17.05
Survival in a Cohort of Patients with
Lung Cancer: The Role of Age and
Gender on Prognosis
Juliana Franceschini, Sérgio Jamnik, Ilka Santoro
Universidade Federal de São Paulo, São Paulo/Brazil
<55 165
Male n(\%) 87 (53)
Smoke n(\%) 136 (82)
Male 78 (90)
Female 58 (74)
Histological type n(\%)
Adenocarcinoma 92 (56)
Squamous Cell Carcinoma 52 (32)
Staging n(\%)
IA/IIIA 34 (21)
IIIB/IV 131 (79)
Deaths n (\%) 83 (50)
Follow-up (months) Median[IIQ] 4.9 [1.3-13.2]
*Chi-square test; † Kruskal-Wallis (Duncan test); ‡oneway ANOVA (Bon
Background: Lung cancer has a high incidence in
Brazil; approximately thirty-four thousand new cases
are diagnosed each year. In Brazil, as in other coun-
tries, the majority of patients diagnosed with lung
cancer are elderly. There are few studies that evaluate
demographic and clinical characteristics, disease
staging, treatment modalities and survival in young
patients, mostly carried out in developed countries.
This study aimed to describe these aspects in patients
with non-small cell lung cancer (NSCLC) according
to age.
Methods: Retrospective cohort consisted of patients
diagnosed with NSCLC followed in a referral hospital
in São Paulo. During the monitoring the survival time
was evaluated. Survival functions were calculated
using the method of Kaplan-Meier. The survival
stratified by age was also obtained, according to
distribution of percentages (less than 55; between
55 and 72 years; older than 72 years). Differences
between survival curves were determined using the
log-rank test.
Results: From January 2000 to July 2015 790 patients
were followed, 165 aged less than 55 years, 423 between
55 and 72 years and 202 older than 72 years. Higher
incidence of adenocarcinoma was seen at the groups up
to 72 years. 575 (73\%) patients with advanced disease
(IIIB-IV stages) were observed. The median five-year
survival was 12 months [46-4]. The survival of patients
in different age groups was not different.
Conclusion: In the age group of younger patients (<55)
women predominated, histological type adenocarcinoma
was more frequent, and there were more patients with
advanced stage at the diagnosis and a higher percentage
of smokers in both genders.
Keywords: lung cancer, age, survival
�55<72 423 �72 202 p
279 (66) 127 (63) 0.012*
363 (86) 165 (82) 0.34*
263 (94) 121 (95) 0.21*
100 (69) 44 (59) 0.10*
0.13*
216 (51) 91 (45)
170 (40) 91 (45)
0.057*
127 (30) 52 (26)
294 (70) 150 (74)
232 (55) 105 (52) 0.56*
6.5 [2.0-16.3] 4.4 [1.4-12.9] 0.07†
ferroni test).
OA17.02 Potential Health and Economic Consequences of Organized vs Opportunistic Lung Cancer Screening in Canada
Background
Methods
Results
Conclusion
Keywords
OA17.03 Insurance Type Influences Stage, Treatment, and Survival in Asian American Lung Cancer Patients
Background
Methods
Results
Conclusion
Keywords
OA17.05 Survival in a Cohort of Patients with Lung Cancer: The Role of Age and Gender on Prognosis
Background
Methods
Results
Conclusion
Keywords
Risk factors for lung cancer: a case-control study in Hong Kong women
Author(s): Yuk-Lan Chiu, Xiao-Rong Wang, Hong Qiu and Ignatius Tak-Sun Yu
Source: Cancer Causes & Control, Vol. 21, No. 5 (May 2010), pp. 777-785
Published by: Springer
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Cancer Causes Control (2010) 21:777-785
DOI 10.1007/s 10552-0 10-9506-9
ORIGINAL PAPER
Risk factors for lung cancer: a case-control study
in Hong Kong women
Yuk-Lan Chiu · Xiao-Rong Wang · Hong Qiu ·
Ignatius Tak-Sun Yu
Received: 19 March 2009/ Accepted: 6 January 2010 /Published online: 19 January 2010
© Springer Science+Business Media B.V. 2010
Abstract To identify etiological connections of lung
cancer in Chinese women in Hong Kong, who are among
the highest in lung cancer incidence and mortality, we
conducted a case-control study, in which 279 female lung
cancer cases and 322 controls were selected and frequency
matched. A variety of information, including dietary habits,
occupational history, smoking, domestic environmental
exposures, and family history of cancer was collected, and
their associations with lung cancer were analyzed with
logistic analysis approach. In addition to positive associa-
tions with exposures to cooking emissions and to radon at
home, smoking and family cancer history, we observed that
increasing consumption of meat was linked to a higher risk,
whereas consumptions of vegetables had a strong protec-
tive effect against lung cancer. Moderate consumption of
coffee appeared to be beneficiai against the disease. Those
never employed and domestic helpers were at a higher risk.
The results indicated that environmental exposures, risky
personal behaviors, or lifestyle, as well as family cancer
aggregation are among important contributors to the high
incidence of lung cancer in Hong Kong females.
Keywords Lung cancer · Risk factors ·
Case-control study · Chinese women
Abbreviations
ETS Environmental tobacco smoke
RRE Residential radon exposure
ORs Odds ratios
Y.-L. Chiu - X.-R. Wang · H. Qiu · I. T.-S. Yu (El)
School of Public Health and Primary Care, The Chinese
University of Hong Kong, 4/F, School of Public Health, Prince
of Wales Hospital, Shatin, NT, Hong Kong SAR, China
e-mail: [email protected]
Introduction
Lung cancer is a leading cause of cancer mortality in Hong
Kong women, accounting for about one-third of cancer
deaths [1]. Its age standardized incidence rate reached the
highest around the world in the early 1990s [2] and was
only surpassed by US females in 2000 [3]. Apart from
Hong Kong, the high incidence and mortality rate were
also reported among Chinese women living in mainland
China [4], as well as in other countries [5-7], indicating a
consistent result in this ethnic group.
A number of epidemiological studies were conducted to
explore possible causation of lung cancer, in which ciga-
rette smoking was found to be a major culprit in Chinese
men [8]. However, smoking cannot adequately explain the
high incidence in Chinese females, due to the fact that
smoking in Chinese women in Hong Kong and in mainland
was so uncommon, ranging from 3 to 5\% [9]. Obviously,
there are some other known and unknown risk factors that
could be responsible for the excess risk among the
population.
Lung cancer is a multifactor-causing disease, which may
be related to both environmental exposures and genetic
factors. To gain a more complete understanding about the
risk factors for lung cancer and provide a sensible expla-
nation for the high risk among this ethnic population, we
conducted a population-based case-control study in Hong
Kong Chinese women, in which a variety of factors was
examined, including environmental exposures, dietary
factors, family cancer history, occupations, as well as
active and passive smoking. In our previous data analysis
using the same database, we evaluated the effects of
exposure to cooking emissions and smoking on lung cancer
[10, 11], both of which were found to be potent risk factors
in these women. In another recent report [12], we
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778 Cancer Causes Control (2010) 21:777-785
determined the associations of previous lung diseases and
family cancer history with the occurrence of lung cancer.
In the present analysis, we attempt to provide an overall
picture of risk factors in the population using integrated
data covering a wide range of variables including occu-
pations and detailed dietary factors, which has been rarely
done in addressing etiological issues of lung cancer in
Hong Kong population.
Subjects and methods
The study was approved by the ethics committees of both
the Chinese University of Hong Kong and Queen Elizabeth
Hospital. Details of subject selection were described
elsewhere [10]. Briefly, a total of 279 female patients aged
30-79 years were recruited from the largest oncology
center in Hong Kong, with the criteria of newly diagnosed
primary carcinomas of the lung (International Classifica-
tion of Disease, Ninth Revision code 162) from 1 July 2002
to 30 June 2004. The cancer cases were confirmed histo-
logically according to the WHO histological typing of lung
tumors [13]. At the same time, 322 control subjects were
selected from the same residential areas from which the
cases were selected. The controls had no history of phy-
sician-diagnosed cancer at any site and were frequency-
matched to the cases in 10-year age groups.
Data collection
Person-to-person interview was administered using stan-
dardized questionnaire in local dialect. The collected
information included detailed active smoking history,
environmental tobacco smoking (ETS) exposures at home
and at workplace, cooking practices since childhood, resi-
dential radon exposure, family cancer history, dietary
habits, occupations and education level.
Smoker was defined as one who had ever smoked more
than 20 packs of cigarettes in lifetime, or more than one
cigarette a day, or more than one cigar a week for 1 year.
ETS exposure was defined among nonsmokers as having
lived or worked with smoker(s) for at least 1 year and was
regularly exposed to tobacco smoke. Regular exposure was
defined as at least 1 h a day. We further divided ETS
exposure into three categories, i.e., exposure at either home
or work, at both home and work, and none at all.
We made a great effort to collect detailed information
on cooking practice. A composite index - the cooking dish-
years was constructed to quantify the regular cooking
habits in terms of the frequency and the duration of
cooking, as well as three cooking methods (stir-frying,
frying, and deep-frying), as described previously [10]. One
stir-frying dish-year means cooking one stir-fried dish daily
for a year. The total cooking dish-years was calculated by
summing up the stir-frying dish-years, frying dish-years
and deep-frying dish-years. The total cooking dish-years
was used to express the amount of exposure to cooking
emissions.
Exposure to radon at home was assessed based on
detailed information about the lifetime residences (floor
level, building material and wall surface covering materi-
als, building age, and window opening practices, according
to information available from a territory-wide indoor radon
survey conducted in Hong Kong. The radon exposure was
expressed as residential radon exposure index (RRE) [10].
In addition, information on diagnosed cancer in the lungs
and any other site in first degree relatives (parents and
siblings) and occupation, including job titles and job tasks
according to the coding manual used for the Hong Kong
Census [14] was gathered. Occupations were grouped into
four categories: (1) professional/clerical/sales, (2) never
employed/domestic helper, (3) cleaners, and (4) construc-
tion/industry/sewer workers.
In collection of data on diet, a reduced version of the
Diet History Questionnaire designed by the National
Cancer Institute was used [15]. Subjects were asked about
their dietary habits during the past 5 years before the
interview for controls, and prior to becoming ill for cases.
The data included the frequency and amount of eating
following groups of foods: (1) dark green vegetables, (2)
orange or yellow vegetables, (3) all kinds of meat, (4) all
kinds of fresh fruits (total fruits), (5) pickled vegetables, (6)
supplement of multivitamins, and (7) coffee drink. Con-
sumptions of the first three groups of food were quantified
as average numbers of servings (one serving = 80 gram)
per day /week/month, while the second three groups were
expressed as the frequency of consumption. A coffee
drinker was defined as one who drank at least one cup of
coffee per week for 6 months or more. Coffee drinking was
further quantified as cup-years, i.e., one cup-year means
drinking one cup of coffee per day for 1 year.
Statistical analysis
Unconditional logistic regression was applied to estimate
associations of potential risk factors with lung cancer.
Basically, three models were constructed to obtain odds
ratios (ORs) for lung cancer. The first model was to esti-
mate the main effect of each of the potential risk factors
adjusted by age (there was a residual confounding effect),
employment and years of education. Smoking amount was
categorized as less than 25 and 25 or more pack-years.
Similarly to our previous practice [10, 11], exposure to
cooking emissions was also categorized into four groups
using intervals of 50-dish years. The group of professional/
clerical/sales workers who were assumed to be exposed to
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Cancer Causes Control (2010) 21:777-785 779
minimum potential hazards associated with lung cancer
served as reference group. The second model was con-
structed to estimate the effects of smoking, total dish-years,
family cancer history, radon index, and occupations, where
all of these variables were included all at once, along with
age, education, consumptions of total fruits, and vegeta-
bles. The final model was constructed to estimate the
effects of dietary factors and coffee consumption, in which
all of the dietary variables and coffee consumption were
included all at once. In addition, all of other variables that
were found to be significant predictors in the second model
were included in the final models. All of the three models
were fit using data of all subjects and that of nonsmokers
alone. In the latter case, ETS was adjusted as well.
Finally, we made an estimation of population attribut-
able fraction (PAF) in all subjects and in nonsmokers,
respectively, based on the following method: PAF -
1 - ]Γ ^ for multiple categorical variables [16], where Pi
is the proportion of all cases that are in the stratum i, and
OR/ is an adjusted odds ratio in the stratum /.
PAF = ÎTT^u^î)for binary variables [17], where Pe is
the prevalence of exposure in the control population and
OR is an adjusted odds ratio for exposure to the indepen-
dent variable under study.
Results
Average age was around 65 years for both case and control
groups, and marital status was similar in the two groups
(Table 1). There were significant differences between the
two groups in education and employment, in which lower
education levels and more never employment were seen in
cases than in controls (p < 0.05). The majority of lung
cancer cases were identified as adenocarcinoma (62\%),
whereas squamous cell, large and small cell types
accounted for a small proportion, respectively.
The values of total dish-years and radon index were
significantly higher in cases than in controls (Table 2).
Likewise, smoking, heavy smoking (>25 pack-years) and
family cancer history were more commonly seen in the
cases. Total dish-years, smoking status, pack-years, and
radon index were associated with increased risk of lung
cancer. Furthermore, there were exposure-response trends
in total dish-years and smoking pack-years (Table 2).
Family history of lung cancer and any cancer also
increased the risk. All of the associations remained statis-
tically significant when all of relevant factors were taken
into account, while the association with radon index was
marginally significant. Among the four occupational cate-
gories, more cases were found in the category of never
employed/domestic helpers than the controls (27 vs. 16\%).
The adjusted OR in relation to never employed/domestic
Table 1 Demographic features in cases of lung cancer and controls
Cases (n = 279) Controls (n = 322)
Mean ageab, years 65.4 (10.6) 64.8 (10.6)
Education (\%)
>7 years 56 (20.4) 86 (26.7)
<6 years 1 12 (40.7) 143 (44.4)
Nil 107 (38.9) 93 (28.9)
Employment (\%)
Yes 221 (80.1) 285 (88.5)
No 55(19.9) 37(11.5)
Marital status (\%)
Married 176 (63.8) 206 (64.0)
Widowed 83 (30.0 104 (32.3)
Single/divorced 17 (6.2) 12 (3.7)
Histological type (\%)
Adenocarcinoma 172 (62.4) -
Squamous cell 24 (8.6)
Large call 10 (3.6)
Small cell 9 (3.2)
Unspecified 62 (22.2)
a Mean age at diagnosis (cases) or contact (controls)
b Standard deviation in parenthesis
helpers was 2.6 times, in comparison with clerical/sales
workers. An upward risk was also seen in cleaners and
other industrial workers. In the full model, all of the above
variables were adjusted each other, in addition to age,
education, consumption of total fruits, and vegetables.
The above analyses were also performed in nonsmokers
after 66 smoking cases and 30 smoking controls were
excluded. A slightly elevated risk was observed in relation
to ETS at either home or work (OR = 1.14, 95\% CI, 0.68,
1.93) and at both home and work (OR = 1.30, 95\% CI,
0.72, 2.35). The strength of associations with family cancer
history, radon index, and occupations was approximate to
that observed in all subjects. However, a greater risk was
observed in cooking dish years in nonsmokers, which
showed a clearer exposure-response trend (OR: 1.24, 95\%
CI: 0.96, 2.01 in the category of 51-100; OR: 2.82, 95\%
CI: 1.48, 5.35 in 101 -150; OR: 4.24, 95\% CI: 2.12, 8.47 in
over 150).
In determination of the potential effects of dietary fac-
tors on lung cancer, a full model was constructed with all
variables of the dietary factors along with age, employ-
ment, education, total dish-years, smoking, family cancer
history, and radon index. As shown in Table 3, a higher
risk was seen in increasing consumption of meat. Con-
sumption of 1 serving/day or more was related to a double
risk of that below 1 serving/day. Pickled vegetables
slightly elevated the risk. On the other hand, consumptions
of dark green vegetables and yellow/orange vegetables
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780 Cancer Causes Control (2010) 21:777-785
Table 2 Main effects of selected risk factors in all subjects
Variables Prevalence (n, \%)a Main effectb Full model0
Cases (n = 279) Controls (n = 322) ρ values OR (95\% CI)d OR (95\% CI)
Total dish-years 0.001<50 87 (3 1 .5) 1 34 (4 1 .7) 1 .00 1 .00
51-100 83 (31.0) 1 12 (34.9) 1.12 (0.75, 1.69) 1.12 (0.72, 1.74)
101-150 46(17.1) 45(14.0) 1.53(0.91,2.58) 1.87(1.05,3.30)
>150 52(19.4) 30(9.4) 2.53(1.44,4.45) 2.87(1.56,5.29)Smoking <0.001No 213(76.3) 292(90.7) 1.00 1.00
Yes 66(23.7) 30(9.3) 3.02(1.84,4.95) 2.57(1.49,4.43)Pack-years <0.001
<25 30(10.8) 19(5.9) 2.18(1.16,4.08) 1.83(0.92,3.64)
>25 34(12.2) 10(3.1) 4.61(2.17,9.76) 3.72(1.63,8.46)
Radon index 12.73 (1.57) 12.45 (1.23) 0.016 1.15 (1.02, 1.29) 1.12 (0.98, 1.27)Occupations 0.00 1Clerical/sales 23(8.2) 48(14.9) 1.00 1.00
Never employed/ 76 (27.3) 52 (16.1) 2.71 (1.40, 5.25) 2.64 (1.28, 5.48)
domestic helper
Cleaners 62(22.2) 65(20.2) 1.75 (0.90, 3.41) 2.24(1.08,4.65)
Others6 1 1 8 (42.3) 1 57 (48.8) 1 .43 (0.79, 2.60) 1 .74 (0.90, 3.34)
a The numbers may vary with the variable categories due to some missing values
b Adjusted for age, employment, and years of education
c Full model included age, years of education, total dish-years, smoking, family cancer history, radon index, occupations, intake of total fruits,
and vegetables
d 95\% confidence interval
e Others including all industry and sewer workers
were inversely related to lung cancer risk, both of which
showed a gradient with increasing amount. A similar trend
was also observed in consumption of multivitamins, but the
number of subjects in either irregular or regular con-
sumption was small. In addition, consumption of coffee
ranging from 1 to 10 coffee-years significantly lowered the
risk. However, heavier drinkers, i.e., 10 or more coffee-
years, tended to be associated with a slightly increased risk.
When the similar full model was fit by restricting data to
nonsmokers (data not shown), the directions and strengths
of the above associations were approximate to those
observed in all subjects. There was a slight difference seen
in the effect of coffee consumption in nonsmokers: adjus-
ted OR related to heavier coffee consumption was 1.62
(95\% CI, 0.18, 0.78), somewhat greater than that obtained
from all subjects, while a similar OR remained in the
category of light coffee consumption (OR, 0.37; 95\% CI,
0.18, 0.78).
An estimate of population-attributable fraction in all
study subjects revealed that about 27\% of lung cancer could
be attributable to exposure to cooking emissions (Table 4).
The fraction attributable to smoking, domestic radon expo-
sure, low vegetable intake, and family cancer history ranged
between 16 and 30\%. In addition, about 9\% of lung cancer
could be explained by consumption of meat with 95\%
confidence interval of -20 and 29, indicating the point
estimate was not stable. In the calculation that restricted to
lifetime nonsmokers, there was not much difference from
those obtained from all of the subjects, with the exception of
a higher fraction of lung cancer (35\%) that could be attrib-
utable to exposure to cooking emission.
Discussion
Lung cancer is the leading neoplasm in many countries, in
terms of both incidence and mortality. Although cigarette
smoking is a major recognized cause, which accounts for
80-90\% of lung cancer cases, only a small fraction of
smokers (1-15\%) develop lung cancer [18]. In this study,
majority of the subjects were nonsmokers. Smoking cer-
tainly cannot fully explain the high incidence and mortality
of lung cancer experienced by Chinese women in Hong
Kong. Clearly, other etiological factors can independently
(in the absence of smoking) or jointly (in conjunction with
smoking) cause lung cancer [19]. In our previous analyses
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Cancer Causes Control (2010) 2 1 :777-785 78 1
Table 3 Main effects of dietary factors in all subjects
Variables Prevalence (w, \%)a Main effect0 Full model0
Cases (n = 279) Controls (n = 322) ρ values OR (95\% CI)d OR (95\% CI)
Intake of meat 0.012
<1 serving/day 40(14.6) 69(21.5) 1.00 1.00
>l-2 serving/day 160 (58.4) 151 (47.0) 2.02 (1.22, 3.33) 2.69 (1.55, 4.68)
>2 serving/day 74(27.0) 101(31.5) 1.49(0.86,2.57) 2.10(1.15,3.84)
Intake of pickled vegetables 0.1 15
<1 time/month 68(25.0) 100(31.2) 1.00 1.00
1-3 times/month 119 (43.8) 142 (44.2) 1.18 (0.77, 1.81) 1.16 (0.73, 1.85)
>1 time/week 85 (31.2) 79 (24.6) 1.25 (0.77, 2.01) 1.27 (0.75, 2.14)
Intake of dark green vegetables <0.001
<1 serving/day 64(22.9) 39(12.1) 1.00 1.00
>l-2 serving/day 77 (27.6) 67 (20.8) 0.83 (0.47, 1.46) 0.88 (0.48, 1.61)
>2 serving/day 133 (47.7) 216 (67.1) 0.45 (0.28, 0.75) 0.51 (0.29, 0.88)
Intake of yellow/orange vegetables <0.001
<1 serving/week 146(52.3) 93(28.9) 1.00 1.00
>l-2 serving/week 77 (327.6) 1 14 (35.4) 0.45 (0.30, 0.69) 0.48 (0.31, 0.76)
>2 serving/week 52 (18.6) 113 (35.1) 0.35 (0.22, 0.55) 0.41 (0.25, 0.67)Intake of total fruit 0.004
<1 time/day 85 (30.8) 72 (22.4) 1.00 1.00
1 time/day 126 (45.7) 137 (42.5) 0.95 (0.62, 1.47) 0.98 (0.61, 1.58)
>2 times/day 65 (23.5) 1 13 (35.1) 0.62 (0.38, 1.00) 0.81 (0.47, 1.38)
Supplemental multi vitamins 0.019Never 245(92.1) 267(84.5) 1.00 1.00
Irregularly 9 (3.4) 15 (4.8) 0.76 (0.30, 1.90) 0.70 (0.25, 1.94)
Regularly 12 (4.5) 34 (10.7) 0.43 (0.21, 0.89) 0.38 (0.17, 0.82)Coffee consumption 0.005Never 211(77.0) 246(76.7) 1.00 1.00
1-10 coffee-years 22 (8.0) 47 (14.6) 0.43 (0.23, 0.79) 0.41 (0.21, 0.78)
>10 coffee-years 41 (15.0) 28 (8.7) 1.36 (0.77, 2.43) 1.30 (0.70, 2.42)
a The numbers may vary with the variable categories due to some missing values
b Adjusted for age, employment, and years of education
c All variables in the table were put in the model all at once, along with adjustment for age, employment, years of education, total dish-years,
smoking, family cancer history, and radon index. d95\% confidence interval
[10, 11], we found that smoking and exposure to cooking
emission were potent risk factors for lung cancer in the
Hong Kong women, in which the two factors appeared to
act independently. We also observed that a positive family
history of any cancer was associated with over twofold risk
of a negative family history [12]. The present analysis
reconfirmed the associations, while additional factors, such
as dietary habits, occupations, and exposure to radon at
home were adjusted simultaneously. The current study
further suggested that the exposure to cooking fume might
explain about 26\% of lung cancer occurring in the whole
group, and 35\% in nonsmoking women. Nearly 16\% of
lung cancer could be attributable to cigarette smoking, and
about 22\% to residential exposure to radon. More impor-
tantly, this study evaluated the roles of dietary habit and
occupations in the development of lung cancer, while
taking into account of all other factors, such as smoking,
exposure to cooking emission, and family cancer history.
The results added additional information to help under-
stand lung cancer etiology in Hong Kong women.
The link of dietary factors to lung cancer as well as other
cancers has been increasingly addressed [20, 21]. Diet is
believed to play a major role in cancer etiology and pre-
vention. However, few studies were available with respect
to which specific dietary factors are most closely linked to
lung cancer in Chinese population. In this study, we col-
lected detailed dietary data in both frequency and quanti-
tative assessment. We found inverse associations of lung
cancer with vegetables, multivitamins, and moderate con-
sumption of coffee, and a positive association with total
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782 Cancer Causes Control (2010) 21:777-785
Table 4 Population-attributable fractiona of lung cancer associated
with risk factors
Risk factors Population-attributable fraction (95\% CI)b
All subjects Nonsmoking subjects
Total dish-yearsc 26.5 (12.4, 36.4) 34.9 (22.3, 43.5)
Smoking 15.8 (7.2, 26.9)
Residential radon 22.5 (3.5, 36.1) 21.6 (0, 36.4)
Low vegetable intake 29.9 (8.8, 44.2) 30.7 (8.6, 45.2)
Family cancer history 15.8 (6.4, 27.1) 16.0 (5.8, 28.3)
a Adjusted for age, years of education, occupations, and intake of
total fruit. In addition, total dish-years, smoking, family cancer his-
tory, radon index, and vegetables were adjusted each other. The least
exposed (total dish-years, residential radon, low vegetable intake) and
no exposed (smoking, family cancer history) were reference groups
b 95\% confidence interval
c One dish-year means cooking one stir-fried dish daily for a year
meat. These associations were independent of other risk
factors or confounders being considered. In addition, we
observed a favorable effect of increasing intake of total
fruits and an adverse effect of pickled vegetables, which
were consistent with a previous Hong Kong study [22],
though neither of them was significant.
Intake of vegetables, including dark green and yellow/
orange vegetables, was found to be related inversely to the
risk of lung cancer. There appeared a stronger association
with yellow/orange vegetables, showing lower odds ratios
with increasing intake amount. Intake 1 or more serving
per week might be related to a reduced risk by half, in
comparison with intake less than 1 serving per week. The
result was in line with the previous studies showing that
individuals with high dietary intake of vegetables had a
lower risk for lung cancer than those with low vegetables
intake [21]. Low vegetable intake was found to contribute
30\% to the cancer risk in this population. Fruits and veg-
etables are the major dietary source of antioxidant micro-
nutrients, such as vitamin A, vitamin C, lycopene, beta-
carotene, lutein [23, 24]. Epidemiological data generally
indicated a stronger protective association for fruits than
vegetable consumption [25]. In this study, we did not
observe a stronger association with fruits, however. A
possible explanation might be that the sample size was not
big enough given the wide range of confidence intervals.
Further studies with larger sample sizes are necessary to
confirm the association of fruits with lung cancer in Hong
Kong women.
Intake of multivitamins was also found to be inversely
associated with lung cancer risk, in which regular intake
had a stronger effect than irregular intake. Anticarcino-
genic effects of vitamin A, C, D, and Ε have been sug-
gested in both population studies and experimental studies
[25-27]. The evidence for intake of vitamin C and a variety
of carotenoids or antioxidant index suggested protective
associations [28]. It should be pointed out, however, that
there were only a small number of the women who took
vitamin supplement in this study. Therefore, caution should
be given to the interpretation of the result.
Meat intake was another dietary factor found to be
associated with lung cancer. The risk in those who ate one
serving or more (over 80 g) per day was more than twofold
of that in those eating less. The positive association with
meat consumption was consistent with some other studies
conducted in different populations [29, 30]. Most previous
studies showed a moderately elevated risk that was asso-
ciated with higher intake of fat, meat, or cholesterol
[30-32], based on which the World Cancer Research Fund
(WCRF) concluded that diets high in total fat, saturated/
animal fat, and cholesterol possibly increase the risk of
lung cancer [25]. In our study, meat intake could explain
approximating 9\% of lung cancer. It was worthwhile to
point out that the variable of meat intake in this study
referred to all kinds of meat intake, including red meat,
poultry, and seafood. It has been suggested the link
between fat and cancer risk depends on the type of fat
consumed rather than total fat intake [28]. Consumption of
red meat was especially thought to be linked to lung cancer
and other cancers [33]. Therefore, the association between
(red) meat intake and lung cancer might have been diluted
in our study because of all kinds of meat consumption
included. The Population Attributable Fraction could be
bigger if only red meat intake was considered. Unfortu-
nately, we were not able to separate the effect of red meat
intake from others with the current data. It certainly
deserves to be addressed in the future studies. The mech-
anism for the positive association with high meat intake has
not been clearly understood, but mutagens and carcino-
gens, especially compounds known as heterocyclic amines
(HCAs), has been identified in meats cooked at high tem-
peratures [34, 35], which may be responsible for increasing
lung cancer risk.
The link of coffee consumption to lung cancer was
another interesting finding. The light drinking (1-10 cof-
fee-years) was associated with a decreased risk, while
slightly elevated risk was seen in heavier drinking. Previ-
ous studies reported a beneficial effect of consumption of
coffee, especially decaffeinated coffee, on breast cancer
[36] and colorectal cancer [37]. On the other hand, caffeine
was found to have a carcinogenic effect and might elevate
cancer risk [38, 39]. Among a limited number of studies
examining coffee consumption and lung cancer, some
suggested elevated risks associated with increasing coffee
consumption [40]. A few studies, however, reported that
consumption of decaffeinated coffee was associated with a
statistically decreased risk of lung cancer, which indicated
a protective effect against lung cancer [41, 42]. We
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Cancer Causes Control (2010) 21:777-785 783
detected an inverse relationship with moderate coffee
consumption. Nevertheless, there were only a small num-
ber of coffee drinkers and no detailed information on …
AA S 591.01
Baldeep Pabla, LCSW
Research Paper Guidelines
Purpose: This project provides an opportunity for students to develop and/or refine their skills at
researching, collecting, and analyzing primarily data. The project also provides an opportunity
for students to critically assess previous studies in the areas they have chosen for their research
topic to either test out existing information or further a particular question that was lacking from
your literature review.
Each student is expected to undertake and complete a research project that will advance their
own knowledge and skill in some aspects of Asians in an American community.
The Research Paper should be 5-7 double-spaced pages in length, not counting a required APA-
style cover page, in-text citations, and a works cited page. The paper is going to be graded based
on four main sections: Introduction, Method, Results and Conclusion.
In the introduction section, students are required to give an overview of their topic through their
library research. Your task here is to provide me with information about your topic. What have
people written in relation to your topic? If your topic is not directly addressed in your library
research, you should look at a related topic to help you understand and/or put your topic in
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After you present your findings, students are expected to discuss and make some assessment of
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the way it did using concepts presented in readings, class lectures, or class discussions.
In the conclusion section, you are required to summarize your key findings (approximately 3-5
findings). Then, you should discuss the significance and or contributions of your topic to Asian
American community health. Lastly, you will provide some recommendations to future research.
Smoking-Adjusted Lung Cancer Incidence among Asian-Americans (United States)
Author(s): Meira Epplein, Stephen M. Schwartz, John D. Potter and Noel S. Weiss
Source: Cancer Causes & Control , Nov., 2005, Vol. 16, No. 9 (Nov., 2005), pp. 1085-1090
Published by: Springer
Stable URL: https://www.jstor.org/stable/20069562
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Cancer Causes and Control (2005) 16:1085-1090
DOI 10.1007/sl0552-005-0330-6
? Springer 2005
Smoking-adjusted lung cancer incidence among Asian-Americans (United States)
Meira Epplein12*, Stephen M. Schwartz23, John D. Potter12 & Noel S. Weiss23
1 Cancer Prevention Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100
Fairview Avenue N, M4-B402, P.O. Box 19024 Seattle, WA, 98109-1024, USA; 2Department of Epidemiology,
University of Washington, Seattle, WA, USA; * Epidemiology Program, Division of Public Health Sciences, Fred
Hutchinson Cancer Research Center, Seattle, WA, USA
Received 24 January 2005; accepted in revised form 13 May 2005
Key words: Asian Americans, lung cancer, smoking.
Abstract
Objective: Chinese women residing in Asia and Hawaii have low consumption of tobacco but a high incidence of
lung cancer. To explore this question further, we conducted a study of lung cancer among Chinese women residing
in mainland US.
Methods. Using data from NCIs SEER program, we identified residents of Los Angeles County, the San Francisco
Metropolitan Area, and the Seattle-Puget Sound Area who were 50 years or older, diagnosed with cancer of the
lung or bronchus in 1999-2001, with race specified as non-Hispanic white (n = 18,493), Chinese (n = 853), Fili
pino (n = 615), or Japanese (n = 282). The sex-specific observed number of lung cancer cases among each Asian
sub-group was compared to the expected number of lung cancer cases for each Asian sub-group. The expected
number was determined by multiplying the age-, sex-, and geographic area-adjusted incidence rates for non
Hispanic whites by the age- and sex-specific ratio of percentage of current smokers in each Asian sub-group to
whites in 1990, and then by the size of the respective Asian populations.
Results. Chinese women had a four-fold increased risk of lung cancer, and Filipino women a two-fold increased risk,
compared to that expected based on rates in US non-Hispanic whites with a similar proportion of cigarette smokers.
Lung cancer among Chinese, Filipino, and Japanese males, as well as Japanese females, did not deviate from
expected risk. Among Chinese women, the increased risk was largely restricted to adenocarcinoma and large cell
undifferentiated carcinoma.
Conclusions. Chinese female residents of the western US mainland have a much higher risk of lung cancer than
would be predicted from their tobacco use patterns, just as they do in Asia.
Introduction
Considering their relatively low use of tobacco products,
Chinese women residing in Asia and Hawaii have a high
incidence of lung cancer [1-5]. In broad terms, there are
two potential explanations for this: (1) Chinese women
have unusually marked susceptibility to the adverse
effects of cigarette smoke; or (2) Chinese women have a
relatively high level of exposure to other lung carcino
gens. Because the relative risk of lung cancer associated
with smoking is similar in Chinese women and Chinese
men, [1, 3-7] the second hypothesis appears stronger.
Previous studies have examined lung cancer in Chinese
women in Asia and Hawaii in relation to a number of
potential exposures, including dietary factors [1, 4, 8, 9]
hormonal factors [4, 9, 10] air pollution from smoky
coal [11, 12] and heated unrefined cooking oils and
fumes from meat cooking [13-16]. However, the causes
of the excess incidence seen in these women remain
unclear.
* Address correspondence to: Meira Epplein, Division of Public
Health Sciences, Fred Hutchinson Cancer Research Center, 1100
Fairview Avenue N, M4-B402, P.O. Box 19024, Seattle, WA 98109
1024, USA. Ph.: +1-206-667-6034; Fax: +1-206-667-7850; E-mail:
mepplein @ fhcrc.org
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1086 M. Epplein et al.
Studies to determine whether anomalously high lung
cancer incidence is present among Chinese women who
reside outside of Asia and Hawaii could shed further
light on the causes of the disease. We sought to address
this question by analyzing data from population-based
cancer registries and surveys of smoking behavior in
Asian Americans.
Methods
Study population
The focus of the study was lung cancer incidence among
Chinese, Japanese, and Filipino residents of Los Angeles
County, the San Francisco Metropolitan Area
(Alameda, Contra Costa, Marin, San Francisco, and
San Mateo counties), and the Seattle-Puget Sound Area
(the 13 counties of Western Washington) in 1999-2001.
Using the National Cancer Institutes Surveillance,
Epidemiology, and End Results (SEER) program
database [17], we identified residents of the designated
areas above who were 50 years or older, of known race,
and diagnosed with cancer of the lung or bronchus in
1999-2001. The SEER Program began in 1973, collect
ing race-specific data on cancer incidence in several US
states and geographically defined metropolitan areas; at
present, approximately a quarter of the US population
is covered by registries participating in the SEER pro
gram. Denominator data were obtained from the 2000
US Census [18]. As the 2000 Census allowed more than
one race to be reported for each individual, analyses
were conducted separately using two methods of esti
mating the population-at-risk: (1) among persons who
responded to the question of race/ethnicity as being of a
particular, single race (e.g., Chinese); and (2) among
persons who responded to the race/ethnicity question as
being of a particular race either alone or in combination
with any other race. The resulting estimated rates turned
out to be nearly identical for the two methods of
calculating the population-at-risk, and thus the results
of this paper are based on the incidence rates using
persons who responded to the question of race/ethnicity
as being of a single race, since in the SEER data only a
single race is listed.
Race-specific smoking prevalence data were obtained
from the California Department of Health Services
1992 report on tobacco use in California [19]. That
report presents the findings of a University of California
at San Diego telephone survey, conducted in 1990 and
1991, of adults throughout the state, selected by ran
dom-digit dialing, and includes self-reported current
smoking prevalence by race, age, and sex. These data
were chosen for this study because they are the most
detailed data available on smoking prevalence by Asian
racial/ethnic sub-group.
Data analysis
Sex- and age-specific observed lung cancer incidence
rates for non-Hispanic whites were determined by
dividing the number of cases in each five-year age group
by the population-at-risk, in each geographic area. We
sought to calculate the number of lung cancer cases
expected among each Asian sub-group if the sub-group
had experienced the same rate of lung cancer as non
Hispanic whites, adjusted for age, geographic region,
and relative smoking prevalence, separately for males
and females. To do this, we first multiplied the age (in
five-year age groups from 50 to 84 years, along with a
final category of 85 years and older) and geographic
area-specific incidence rates among non-Hispanic whites
by the age-specific (categorized as 25-44, 45-64, and
65 +years) ratio of percentage of current smokers in
each Asian sub-group to whites in 1990. The resulting
figures represent estimates, for males and females, of age
and geographic area-specific incidence rates among non
Hispanic whites that would have been observed if they
had smoked at the respective Asian levels. We then
applied these estimated rates to the age and geographic
area-specific Asian populations, by sex, to produce the
expected number of lung cancer cases for each Asian
sub-group.
The sex-specific risk of lung cancer for each Asian
sub-group, compared to non-Hispanic whites, was then
determined by dividing the observed number of lung
cancer cases by the expected number. The 95\% confi
dence interval (CI) on each observed-expected ratio was
calculated using Silcocks exact procedure based on the
Binomial/Incomplete Beta for data where the expected
estimate is not error free [20, 21]. Lung cancers were
classified as to histologie types according to the Inter
national Classification of Disease - Oncology (ICDO)
[22] as follows: large cell undifferentiated carcinoma
(ICDO 8012, 8013, 8020-8022, 8030, 8031), small cell
carcinoma (ICDO 8040-8045), squamous cell carcinoma
(ICDO 8032, 8050-8076), and adenocarcinoma (ICDO
8140, 8211, 8230, 8231, 8250-8254, 8260, 8310, 8323,
8480-8490, 8550, 8560, 8570-8572).
Results
Included in this analysis were a total of 18,493
non-Hispanic white, 853 Chinese, 615 Filipino, and 282
Japanese residents of three areas of mainland US with
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Smoking-adjusted lung cancer incidence 1087
Table 1. Numbers of cases of primary lung cancer in three western US populations (Los Angeles County, San Francisco Metropolitan Area,
Seattle-Puget Sound Area), 1999-2001
Los Angeles county
Males Females
San Francisco metro- Seattle-Puget Sound Total
politan area area
Males Females Males Females Males Females
Non-Hispanic White 3757 3510 2151 2159 3602 3314 9510 8983
Chinese 212 158 286 157 24 16 522 331
Filipino 222 101 161 76 40 15 423 192
Japanese 101 75 34 30 18 24 153 129
cancer of the lung or bronchus (see Table 1 for the dis
tribution of cases by geographic area). Smoking preva
lence data showed that a smaller proportion of Asian
women, of each racial/ethnic sub-group and age category,
were current smokers than their counterpart non-His
panic white women, whereas the age-specific smoking
prevalence among male Asian racial/ethnic sub-groups
was similar to that of non-Hispanic white men (Table 2).
Chinese women had a four-fold higher risk of lung
cancer than expected based on age, geographic region,
and smoking prevalence (Table 3). Filipino women had
a two-fold higher risk than expected. In contrast,
Filipino men, Chinese men, Japanese men, and Japanese
women did not experience any appreciable difference in
risk from that expected. The higher risk for Chinese
women was present at all three geographic sites.
Among Chinese women, the risks of adenocarcinoma
and large cell undifferentiated carcinoma were elevated
six- and four-fold, respectively, whereas there was no
difference in the risk of small cell carcinoma and, at most,
a modest elevation of the risk of squamous cell carci
noma (Table 4). In Filipino women, the only appreciably
higher lung cancer risk was for adenocarcinoma.
Discussion
The most direct way of assessing smoking-adjusted
incidence of lung cancer by race would be by means of a
multi-racial cohort study in which data on smoking
status are obtained at baseline. To our knowledge, there
are no published results from such a study. Therefore, to
address the issue of whether there is excess lung cancer
considering smoking prevalence among Chinese women
in the US, we were obliged to pursue an indirect ap
proach, using data on smoking among Asians external
to our data on cancer incidence. There are a number of
limitations to this approach that must be considered.
In the data obtained by the California Department of
Health Services [23], smoking status was categorized
simply as current versus other, with no data on dura
tion, intensity, or recency of smoking. If Chinese or
Filipino women who smoke cigarettes are unlike non
Hispanic white women in any of these aspects of
smoking behavior, our results could be biased. The
prevalence data were also collected over the phone, by
self-report, and may have been misreported, although
we have no reason to believe this would vary among the
racial/ethnic groups. Figures for smoking prevalence
similar to those used in the present analysis were ob
tained for Chinese men and women living in Oakland,
California in 1989-1990 [23]. The prevalence data
(whether from Oakland or California as a whole) ob
tained approximately ten years prior to the diagnoses of
lung cancer would seem to be a fairly reasonable choice
in terms of characterizing risk. Nonetheless, if smoking
behavior in any of the populations studied has changed
considerably during the past several decades, the use of
Table 2. Prevalence (\%) of current cigarette smoking among white and Asian Californians, by age and sex, 1990-199Ia
Males Females
25-^4
years
Ratio to
Whites
45-64
years
Ratio to
Whites
65 +
years
Ratio to
Whites
25-44
years
Ratio to
Whites
45-64
years
Ratio to
Whites
65 +
years
Ratio to
Whites
Non-Hispanic White 27.9 1.00 25.5 1.00 13.0 1.00 24.1 1.00 23.8 1.00 12.5 1.00
Chinese 20.9 0.75 19.9 0.78 19.8 1.52 5.5 0.23 2.5 0.11 2.6 0.21
Filipino 29.2 1.05 25.8 1.01 10.6 0.82 14.6 0.61 5.1 0.21 3.4 0.27
Japanese 24.7 0.89 22.1 0.87 11.1 0.85 16.3 0.68 13.4 0.56 8.3 0.66
Source: Burns D, Pierce JP. Tobacco Use in California 1990-1991. Sacramento: California Department of Health Services, 1992.
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1088 M. Epplein et al.
Table 3. Observed lung cancer cases versus those expected,a based on smoking prevalence, among Asians in three western US populations (Los
Angeles county, San Francisco metropolitan area, Seattle-Puget Sound area), adjusted for age and geographic region, 1999-2001
Males Females
Observed cases Expected casesa Relative risk (95\% CI) Observed cases Expected casesa Relative risk (95\% CI)
Chinese 522 632.6 0.8(0.7-0.9) 331 82.3 4.0(3.2-5.1)
Filipino 423 331.5 1.3(1.1-1.5) 192 96.3 2.0(1.6-2.6)
Japanese 153 190.7 0.8(0.6-1.0) 129 145.8 0.9(0.7-1.1)
a Calculated by multiplying the age-specific incidence rate in non-Hispanic whites by the age-specific ratio of smoking prevalence of whites to
each Asian sub-group, and the total then multiplied by the respective age-specific Asian sub-group population-at-risk.
data at a single point in time may provide a misleading
idea of that populations smoking-related burden of
lung cancer.
Other limitations are related to those present in our
sources of data. Regarding accuracy in the reporting of
histologically defined subsets of cancer, a recent study
compared reported histologie codes for lung cancer in
the SEER registry with an independent review of diag
nostic slides, and found reasonably good agreement [24].
The potential for inaccuracy and the inconsistency in the
way in which race information is collected by the SEER
program (i.e., relying largely on medical records) could
lead to misclassification of some cases, particularly
within the Asian sub-groups. In addition, we were un
able to provide rates of lung cancer in Asian-American
women according to country of birth and, if foreign
born, age at migration to the US. Of the Chinese women
whose country of birth was recorded in the SEER
data files, 85-90\% were born outside of the US, and so
our results may well not portray the experience of
American-born Chinese women.
Noting these limitations, our finding of increased risk
of adenocarcinoma and large cell undifferentiated car
cinoma of the lung among Chinese women in mainland
United States, who have a low prevalence of smoking, is
consistent with what has been found among Chinese
women in Asia and Hawaii [1, 3, 25-28]. Although there
has been no examination of potential lung carcinogens,
other than cigarette smoke, that might account for the
high rate among Chinese women in the US mainland, a
number of studies have examined such possible expo
sures among Chinese women in Asia.
Case-control studies in northeast [29] and southeast
[12, 30, 31] China have observed an increased risk of
lung cancer (odds ratios of 1.5-5.8) among non
smoking Chinese women associated with heating coal
indoors or indoor exposure to coal smoke. Among
women with more than 30 years use of a coal stove
in the bedroom, the odds ratio was 18.8 (95\% CI
3.9-29.3) in the northeast city of Harbin [29]. However,
two other case-control studies - one in the north and
one in the south of China - found no association
between indoor exposure to coal smoke and lung
cancer [14, 32].
Results of examinations of unrefined cooking oils
have been more consistent, with all studies observing
some excess risk (relative risks of 2.8 - 9.2) associated
with the inhalation of cooking fumes [4, 14, 29, 31, 33].
A more detailed investigation of this issue found that
use of unrefined Chinese rapeseed oil, compared to
soybean oil, was associated with a 1.4-fold increase in
risk (95\% CI 1.1-1.8) [4]. The excess risk was highest
(2.8, 95\% CI 1.8-4.3) among women using rapeseed oil
who had frequent eye irritation while cooking (a sur
rogate marker of relatively high levels of exposure).
Another study found that a number of highly muta
genic chemicals were emitted when cooking at high
temperatures with unrefined rapeseed oil; specifically,
1,3-butadiene, classified as a probable human carcino
gen by the International Agency for Research on
Cancer [34], had approximately 22-fold higher emis
sions when cooking with unrefined rapeseed oil as
opposed to peanut oil [13]. This agent has also been
detected in cigarette smoke [35]. A study of lung cancer
among Chinese women in Singapore observed an odds
ratio of 2.8 (95\% CI 1.4-5.7) associated with daily stir
frying of meat for 20-30 years prior to the date of
diagnosis among smokers, but no association in non
smokers [15].
There are several other factors that have been exam
ined as potential lung carcinogens, although none could,
plausibly, account for all of the excess risk among
Chinese women relative to women of other races. Diet,
particularly, has been extensively studied, and the excess
risk of lung cancer among the lowest consumers of fresh
fruits, vegetables, and soy has been found to be
between 1.2 and 2.4 [1, 8, 9, 29, 36, 37]. The role of
hormonal and reproductive factors has also been
examined, with decreased risks of lung cancer of
approximately 30-50\% seen in non-smoking women
with longer menstrual cycles and three or more live
births [4, 9].
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The results of our study suggest that, accounting for
their level of cigarette smoking, Chinese female residents
of the western US mainland have an increased risk of
lung cancer, particularly adenocarcinoma of the lung,
just as they do in Asia. From research in Chinese resi
dents in Asia, there are clues as to why this might be so,
and these could be pursued in cohort and case-control
studies in Asian-American women.
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1090 M. Epplein et al.
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etiology of lung cancer in nonsmoking females in Harbin, China.
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30. Du Y-X, Cha Q, Chen X-W, et al. (1996) An epidemiological
study of risk factors for lung cancer in Guangzhou, China. Lung
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(1996) Analysis and estimates of attributable risk factors for lung
cancer in Nanjing, China. Lung Cancer 14: S107-S112.
32. Lei Y-X, Cai W-C, Chen Y-Z, Du Y-X (1996) Some lifestyle
factors in human lung cancer: a case-control study of 792 lung
cancer cases. Lung Cancer 14: S121-S136.
33. Ko YC, Lee CH, Chen MJ, et al. (1997) Risk factors for primary
lung cancer among non-smoking women in Taiwan. Int J
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Humans (1992) Occupational exposures to mists and vapours
from strong inorganic acids and other industrial chemicals, pp. 54:
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35. Brunnemann KD, Kagan MR, Cox JE, et al. (1990) Analysis of
1,3-butadiene and other selected gas-phase componenets in ciga
rette mainstream and sidestream smoke by gas chromatography
mass selective detention. Carcinogenesis 11: 1863-1868.
36. Koo LC (1988) Dietary habits and lung cancer risk among Chinese
females in Hong Kong who never smoked. Nutr Cancer 11:155-172.
37. Xu Z-Y, Brown L, Pan GW, et al. (1996) Lifestyle, environmental
pollution and lung cancer in cities of Liaoning in northeastern
China. Lung Cancer 14: S149-S160.
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Contents
[1085]
1086
1087
1088
1089
1090
Issue Table of Contents
Cancer Causes & Control, Vol. 16, No. 9 (Nov., 2005), pp. 997-1134
Front Matter
Bladder Cancer Risk in Painters: A Review of the Epidemiological Evidence, 1989-2004 [pp. 997-1008]
Cancer …
Understanding
& Improving
Lung Cancer
Treatment in
Asian
Americans &
Pacific Islanders
in the
Community
Setting
A C C C A D V I S O R Y C O M M I T T E E
Jared Acoba, MD
Medical Oncologist
OnCare Hawaii, Inc.
Susie A. Chen, MD
Radiation Oncologist
Pacifi c Radiation Oncology, LLC
Charles F. Miller, MD
Medical Oncologist
Hawaii Society of Clinical Oncology (HSCO)
Ian Okazaki, MD
Medical Oncologist
Straub Clinic & Hospital, Inc.
A S S O C I AT I O N O F C O M M U N I T Y C A N C E R
C E N T E R S ( A C C C )
Jennie R. Crews, MD, MMM, FACP
2016-2017 President
Christian Downs, JD, MHA
Executive Director
Amanda Kramar
Director, Provider Education
Marianne Gandee, MA
Assistant Director, Provider Education
Monique J. Marino
Manager, Publications
A C K N O W L E D G E M E N T S
ACCC and HSCO would like to extend special thanks to the
members of the Advisory Committee and to those who participated
in this project by providing valuable input and feedback.
Keola Beale, MD
Medical Oncologist
Kaiser Permanente Hawaii Region
Christa Braun-Inglis, MS, APRN, FNP-BC, AOCNP
Oncology Nurse Practitioner
Kaiser Permanente Hawaii Region
Jonathan Cho, MD
OnCare Hawaii, Inc.
Enza Esposito-Nguyen, RN, MSN, ANP-BC
Urologic and Thoracic Oncology,
Nurse Navigator/Nurse Practitioner
Center for Cancer Prevention and Treatment
St. Joseph Hospital, Orange
Jamie Keck, PhD
Clinical Cancer Genomics Program Manager,
Senior Research Associate Corless Lab
OHSU Knight Cancer Institute
Jeanette Koijane, MPH
Executive Director
Kokua Mau
Anthony Lim, MD
Hematologist/Oncologist
Hawaii Pacifi c Oncology Center
Renato Martins, MD, MPH
Medical Director, Outpatient General Oncology/Hematology
Medical Director, Thoracic/Head and Neck Oncology
Seattle Cancer Care Alliance
Laeton Pang, MD, MPH
Radiation Oncologist
Pacifi c Radiation Oncology, LLC
Mitra Rado, MN, FNP-C, ARNP, AOCNP
Implementation Engineer/IT
Kadlec Clinic Hematology & Oncology
Thomas Rado, MD
Medical Oncologist
Kadlec Clinic Hematology & Oncology
David Tamura, MD
Hematologist/Oncologist
OnCare Hawaii, Inc.
Nancy Thompson, MSN, RN, AOCNS
Director of Quality and Clinical Practice
Swedish Health Services, Swedish Cancer Institute
Cecilia Zapata, MS, MHA
Director, Regional/Global Network and Physician
Educational Outreach
Seattle Cancer Care Alliance
C O N T R I B U T O R S
L U N G C A N C E R T R E AT M E N T I N T H E A A P I C O M M U N I T Y I a c c c - c a n c e r. o r g / l u n g I 1
U N D E R S TA N D I N G & I M P R O V I N G
L U N G C A N C E R T R E AT M E N T I N A S I A N
A M E R I C A N S & PA C I F I C I S L A N D E R S
I N T H E C O M M U N I T Y S E T T I N G
Introduction & Survey Results 2
Health Disparities Among AAPI Patients 3
Limited Access Healthcare Issues & 5
Practical Suggestions for Improvement
Communication & Cultural Barriers & 6
Practical Suggestions for Improvement
Lung Cancer Management & Practical 8
Suggestions for Improvement
Clinical Research 10
Conclusion 10
References 11
TA B L E O F C O N T E N T S
F I G U R E 1 .
M E M B E R
P R O G R A M S
S U R V E Y E D
■ 36\% Hawaii
■ 46\% California
■ 15\% Washington
■ 3\% Oregon
LEGEND
n = 33
Lung cancer is the leading cause of cancer death and the second most common cancer among both men and women in the United States. Moreover, Asian Americans were the fi rst U.S. racial/ethnic group to experience cancer as the leading cause of death.1 Asian Americans, Native Hawaiians, and Pacifi c Islanders (AAPIs) represent one of the
fastest growing racial groups in the United States. States with the highest AAPI populations include Hawaii, California, and
New York.2 Given that AAPI patients face disparities in healthcare, the Association of Community Cancer Centers (ACCC), in
collaboration with the Hawaii Society of Clinical Oncology (HSCO), launched a project to gain a deeper understanding of the
unique cultural, economic, and demographic needs of AAPI patients with lung cancer in order to fi nd ways to improve the
diagnosis and treatment of this vulnerable patient population. An Advisory Committee provided oversight over this
initiative, which included an online survey of 33 cancer programs in California, Hawaii, Oregon, and Washington (Figure1).
(This number represents 1/3 of the ACCC member programs in those states.) ACCC and HSCO also conducted several
interdisciplinary focus groups and a number of in-depth interviews with oncologists in Hawaii to identify key barriers and
opportunities for improvement when managing AAPI patients with lung cancer.
2 I A S S O C I AT I O N O F C O M M U N I T Y C A N C E R C E N T E R S I a c c c - c a n c e r. o r g
To gain a better understanding of some of the key issues providers face when treating AAPI patients with lung cancer, ACCC asked about the need for improvement in specifi c areas. Survey respondents indicated that the greatest needs were around patient education and patient understanding of treatment options, especially
regarding end-of-life decisions (Table 1).
S U R V E Y R E S U LT S
I N T R O D U C T I O N
Patient’s openness and
willingness to speak about
hospice and end-of-life
decisions
Patient’s level of
understanding about lung
cancer and treatment
options
Patient’s compliance and
adherence to treatment
recommendations and
medical advice
Quality of communication
between the patient and
the members of the cancer
care team
LEGEND
■ = Small Need
■ ■ ■ ■ ■ = Signifi cant Need
TA B L E 1 .
S U R V E Y R E S U LT S
O F N E E D S
A S S E S S M E N T
A
S
IA
N
A
M
E
R
IC
A
N
N
A
T
IV
E
H
A
W
A
II
A
N
O
T
H
E
R
P
A
C
IF
IC
IS
L
A
N
D
E
R
■ ■ ■
■ ■
■
■
■ ■ ■
■ ■ ■
■ ■
■
■ ■ ■ ■ ■
■ ■ ■ ■ ■
■ ■ ■
■ ■ ■
� �� �� ��
36\%15\%
3\%
46\%
L U N G C A N C E R T R E AT M E N T I N T H E A A P I C O M M U N I T Y I a c c c - c a n c e r. o r g / l u n g I 3
The AAPI population represents over 30 countries and ethnic groups that speak more than 100 different languages.
3
In 2011 the population of Asian Americans was estimated at 18.2 million and the largest groups were: Chinese, Filipinos,
Asian Indians, Vietnamese, Koreans, and Japanese.2 The population of Native Hawaiian or other Pacifi c Islanders was
estimated at 1.4 million in 2011 and the largest groups were: Native Hawaiian, Samoan, Guamanian, and Chamorro.2
AAPI patients may face a host of factors that may threaten their health, including infrequent medical visits, language and cultural
barriers, and lack of health insurance.2 Among fi rst-generation AAPI patients, 13.2 percent live in poverty and 4.2 percent are
unemployed.4 Native Hawaiians and other Pacifi c Islanders have higher rates of smoking, alcohol consumption, and obesity than
other minority populations living in the United States.5
Specifi c to lung cancer:6
• Lung cancer is 18 percent higher among Southeast Asians than White Americans.
• Vietnamese have the highest rates of lung cancer among all Asian subgroups.
• Chinese have the highest mortality rates of lung cancer among all Asian subgroups.
• Foreign-born Asians have a higher rate of NSCLC (non-small cell lung cancer) than U.S.-born Asians.
• Smoking rates are signifi cantly higher among Southeast Asians.
Oncology clinicians have also noted that Asian American women who have never smoked have a greater risk for lung cancer
compared to women in other ethnic groups.7 To gain a deeper understanding of why Asian female never-smokers are
at greater risk for lung cancer, researchers from the National Cancer Institute (NCI) collaborated with several other
countries to form the Female Lung Cancer Consortium in Asia and conducted a Genome-Wide Association Study
(GWAS) where they identifi ed three genetic regions that predispose Asian women to lung cancer:
loci at 10q25.2, 6q22.2, and 6p21.32.8
NCI Community Networks Program Centers (CNPCs) that focus on reducing health disparities
among AAPI patients include:9
• Asian Community Cancer Health Disparities Center (cah.temple.edu/acchdc )
• Asian American Network for Cancer Awareness Research and Training (aancart.org)
• Weaving an Islander Network for Cancer Awareness, Research, and Training
(wincart.fullerton.edu)
• Imi Hale – Native Hawaiian Cancer Network (imihale.org)
H E A LT H D I S PA R I T I E S A M O N G A A P I PAT I E N T S
F I G U R E 2 .
TO P A A P I S U B G R O U P S I N T H E U S 3
Country of origin or birth among AAPI community
■ 22\% Chinese (not Taiwanese)
■ 19\% Filipino
■ 16\% Indian
■ 10\% Vietnamese
■ 9\% Korean
■ 6\% Japanese
■ 18\% Other (including Pakistani, Cambodian, Hmong, Thai, Laotian, Taiwanese, Bangladeshi,
Burmese, Indonesian, Napalese, Sri Lankan, Malaysian, and Bhutanese)
� �� �� �� ������
22\%
19\%
16\%
10\%
9\%
6\%
18\%
The AAPI Community
Is Rich With
Diversity
Source: The White House Initiative on Asian Americans and Pacifi c Islanders. whitehouse.gov/administration/eop/aapi/data/critical-issues.
4 I A S S O C I AT I O N O F C O M M U N I T Y C A N C E R C E N T E R S I a c c c - c a n c e r. o r g
F I G U R E 4 .
T H E A A P I C O M M U N I T I T Y: D E M O G R A P H I C S
U.S. minority population by race
The AAPI Community is Projected to
Grow Another 134\% to Over
35.6 Million
Over the Next 40 Years
2000 2010 2020* 2030* 2040* 2050*
10.6 M
15.2 M
19.5 M
24.5 M
29.9 M
The AAPI Community
Grew By
42.97\%
Between 2000 and 2010
35.6 M
80 M
70M
60 M
50 M
40 M
30 M
20 M
10 M
LEGEND ■ Asian American, Native Hawaiians and Other Pacifi c Islanders
■ Black or African American
■ Hispanic or Latino
Population
*Denotes projected estimates
F I G U R E 3 .
C O U N T I E S W I T H T H E H I G H E S T A A P I P O P U L AT I O N
Among people reporting only one race — 2000 and 2010 census
LEGEND
United
States
of America
>500,000
75,000 — 499,999
45,000 — 74,999
30,000 — 44,999
15,000 — 29,999
Source: The White House Initiative on Asian Americans and Pacifi c Islanders. whitehouse.gov/administration/eop/aapi/data/critical-issues.
Hawaii
Honolulu County, HI
591,000 AAPI
Source: The White House Initiative on Asian Americans and Pacifi c Islanders. whitehouse.gov/administration/eop/aapi/data/facts-and-fi gures.
Santa Clara County, CA
618,000 AAPI
Los Angeles County, CA
1.5 million AAPI
Orange County, CA
598,000 AAPI
Queens County, NY
553,000 AAPI
Alaska
Practical Suggestions for Improvement
• Increase awareness about lung cancer screening
programs and insurance coverage for screening tests.
• Leverage community health outreach events to
educate patients and their family members about
lung cancer, health insurance resources, and ways to
improve healthcare access.
• Find ways to engage employer groups that are
willing to disseminate health information to their
employees.
L U N G C A N C E R T R E AT M E N T I N T H E A A P I C O M M U N I T Y I a c c c - c a n c e r. o r g / l u n g I 5
L I M I T E D A C C E S S T O H E A LT H C A R E
F
or many decades, AAPI patients faced extreme challenges accessing healthcare because they lacked health
insurance and relied on Community Health Centers (CHCs). Although the Affordable Care Act has made it possible
for many previously uninsured AAPI patients to receive healthcare coverage, many patients still continue to receive
their care from CHCs because the private practice providers in their communities are not accepting new patients, Medicaid
patients, or patients covered by other third-party insurance plans.
Cultural and educational barriers can impact how AAPI patients access healthcare. Many are not aware of the importance
or availability of screening tests and so they often are diagnosed with advanced lung cancer in an inpatient setting. These
patients may present to the hospital emergency department with severe pulmonary symptoms that have progressed over
time, and this visit to the hospital may be their fi rst contact with a healthcare provider.
Awareness about lung cancer is growing because of the combined efforts of certain cultural and ethnic groups and
religious organizations collaborating with public health departments to offer screening and education. However, these
events are limited and often do not reach elderly patients who may avoid leaving their homes. Many AAPI patients also
have limited access to reliable transportation during the workday. They often depend on family members who have busy
work schedules and public transportation may not be available to take patients to their medical visits. Cancer programs
in these communities have found ways to maximize the use of taxi vouchers or other programs like the American
Cancer Society Road to Recovery Program.10
6 I A S S O C I AT I O N O F C O M M U N I T Y C A N C E R C E N T E R S I a c c c - c a n c e r. o r g
The diverse AAPI population who comes from multiple countries speaks more than 100 different languages.
3
Hence, language and translation can be especially challenging when encountering patients who come from
smaller countries. Although most large hospitals and health systems have reliable access to professional medical
translators, oncology providers working in private practice or in smaller hospitals often struggle to fi nd translators when
they are needed. In certain AAPI cultures, gender barriers may hinder effective communication between a patient and
a translator or a patient and a clinician. These gender-specifi c cultural issues must be navigated carefully by
translators and clinicians if they hope to achieve trust in the patient-provider relationship.
Advances in technology have led to effective video-based translation services in places where live translators
may not be available. A leading example is the Language Access Network’s (LAN) MARTTI (My Accessible
Real-Time Trusted Interpreter), a two-way video and audio medical interpreter service that meets HIPPA data
encryption requirements. However, real-world experience with MARTTI remains a challenge in certain areas
because of the lack of reliable high-speed Internet connectivity that leads to poor video quality and other
user issues.
In many areas, medical interpreters often end up playing a signifi cant role in care coordination as they build
trust and rapport with patients and family members. For certain AAPI ethnicities, the local community may be
very small, so medical translators may end up being related to the patient. These relationships can pose
signifi cant challenges around patient privacy and confi dentiality.
In some situations, family members may offer to translate, but this may present other types of challenges due to
certain AAPI cultural behaviors. For example, adult children may be hesitant and reluctant to give bad news to elderly
family members because they fear that the stress associated with the bad news could lead to worse outcomes.
Or, due to respect for the elders, the grown children may take a paternalistic approach to shield their parents from bad
news. In certain AAPI cultures, the patient’s place in the family—both in terms of gender and age—may impact how other
family members communicate with the patient about health-related issues. This can also impact the clinical decision-
making process among family members who may be struggling with major medical decisions. Studies have also shown
that some of the most common causes for medical errors attributed to insuffi cient patient language profi ciency include:11
• Use of family members, friends, or nonqualifi ed staff as interpreters.
• Clinicians with basic foreign language skills who try to communicate without using
qualifi ed interpreters.
• Cultural beliefs and traditions that affect healthcare delivery.
End-of-life discussions can be extremely challenging, especially if the topic of death and dying is not a culturally
appropriate or acceptable discussion topic. So, although advanced directive documents may be available in different
languages, patients need guidance and assistance around sensitive topics. Clinicians and medical translators working
in the oncology setting need training on these types of cultural competency communication issues so that they can
effectively contextualize their conversations around cultural norms and expectations. For instance, in some cultures,
conversations about death and dying may be considered inappropriate. But, if clinicians explain why they must spend
time discussing an uncomfortable topic, then patients may be more receptive to and understanding of the dialogue.
Several videos covering advanced directives and end-of-life care have been generated in several AAPI languages through
the support of grants. However, these valuable resources (kokuamau.org/resources) remain underutilized because some
clinicians remain unaware of these tools and others do not make the time to recommend them to patients.
C O M M U N I C AT I O N & C U LT U R A L B A R R I E R S
L U N G C A N C E R T R E AT M E N T I N T H E A A P I C O M M U N I T Y I a c c c - c a n c e r. o r g / l u n g I 7
Practical Suggestions for Improvement
• Consider ways to spend more time with patients and family members
during their initial visits in order to cultivate trusting relationships.
• Identify ways to increase the usability of video-based translation
services, especially in programs that do not have reliable access to
translators.
• Find ways to train and equip clinicians and translators to have greater
cultural competency when communicating with AAPI patients about
treatment options, end-of-life care, and other sensitive topics.
8 I A S S O C I AT I O N O F C O M M U N I T Y C A N C E R C E N T E R S I a c c c - c a n c e r. o r g
I
n some areas, over 50 percent of AAPI patients are being diagnosed with lung cancer in the inpatient hospital setting
because they are not receiving appropriate outpatient care in a timely manner. These individuals often present with
severe respiratory symptoms and are admitted from the emergency department. Clinical management and care
coordination often require a strong team-based approach that actively involves a medical translator if the patient is
not fl uent in English.
As more community cancer programs implement a pathology-driven refl exive molecular biomarker testing process
for advanced NSCLC, they must also take into consideration the issues that come when patients are diagnosed
in the inpatient setting. Because so many AAPI patients are diagnosed as inpatients, the Medicare 14-day rule
(which states that CMS will allow independent and hospital-based laboratories to bill separately for certain
complex diagnostic laboratory services that are ordered within a 14-day period after a hospital discharge) may
cause delays in ordering molecular biomarker tests in patients who have advanced stage NSCLC.12 Certain
actionable mutations, such as EGFR, are found more frequently in AAPI patients, so oncologists are eager to
obtain testing information so that they can make informed treatment decisions. In Caucasian patients with
NSCLC, EGFR mutations may be found in approximately 20 percent of cases.13 However, Chinese researchers
found EGFR mutations in 37.5 percent of patients with lung adenocarcinoma.14 The PIONEER study
(NCT01185314) found that the rate of EGFR mutations was 51.4 percent across multiple Asian ethnic groups
with lung adenocarcinoma.15 Lung cancer patients with actionable mutations may also develop treatment
resistance to targeted therapies, and researchers are exploring the various mechanisms that may contribute to
these specifi c resistance patterns.16
Some AAPI patients remain extremely hesitant to accept radiation treatment for lung cancer because they perceive
all types of radiation to be harmful. Historic context can be especially important given that certain AAPI ethnic groups
experienced signifi cant exposure to ionizing radiation from U.S. nuclear weapons testing.17
When treating AAPI patients who have limited English profi ciency, care coordination becomes a signifi cant challenge.
Medical translators often shoulder the responsibility of acting as primary care coordinators, even when they are not
formally trained in care coordination. So, it becomes imperative for all the members of the oncology care team to
communicate clearly with translators who then serve as the primary point of contact with patients and family members.
NSCLC patients who are treated with oral oncolytic medications need more education, monitoring, and follow-up. Limited
health literacy and other communication barriers can make this especially challenging for oncology providers, especially
since these patients now have the responsibility of taking their medications at home.
Appropriate monitoring and follow-up with AAPI patients can also be diffi cult because some patients do not have a reliable
phone number and they depend on other family members who have phones. When an oncology provider, tries to contact
a patient, staff may need to make several phone calls in order to reach the patient. This may complicate communication
workfl ows and create ineffi ciencies when staff is trying to reschedule patients who missed their appointments.
L U N G C A N C E R M A N A G E M E N T
L U N G C A N C E R T R E AT M E N T I N T H E A A P I C O M M U N I T Y I a c c c - c a n c e r. o r g / l u n g I 9
Practical Suggestions for Improvement
• Educate oncology clinicians about lung cancer characteristics that
are unique to AAPI patients and the ongoing research that is actively
exploring these issues.
• Ensure that molecular biomarker testing is performed routinely in
AAPI patients since they have a higher prevalence of certain actionable
mutations, such as EGFR.
• Identify ways to improve care coordination and follow-up, especially
when patients are taking oral oncolytic medications at home.
1 0 I A S S O C I AT I O N O F C O M M U N I T Y C A N C E R C E N T E R S I a c c c - c a n c e r. o r g
C L I N I C A L R E S E A R C H
I
n our focus groups, clinicians noted that AAPI patients who have limited English profi ciency do not have opportunities
to enroll in clinical trials because the informed consent forms are often only available in English. In some limited cases,
informed consent forms may also be available in Chinese, but they are rarely available in other AAPI languages.
The IRB (institutional review board) policies that govern specifi c clinical trials may require consent forms to be written
in native languages to ensure that patients fully understand the risks of participating. Focus group participants
agreed that there is a signifi cant need to revise clinical research regulations and policies in order to allow more
AAPI patients to participate in studies. Given the unique molecular characteristics found in AAPI patients with
lung cancer, more research is needed to explore actionable mutations and patterns of treatment resistance.
A
sian American and Pacifi c Islander patients with lung cancer face challenges receiving care, but
there are clear opportunities to bridge some of those gaps. This project helped to uncover some
key barriers and shed light on practical ways to overcome some of those hurdles so that oncology
clinicians can be more effective when caring for their AAPI patients with lung cancer. There is a greater need
for cultural competency and translation services in the oncology community. When combined effectively, these
resources can properly equip oncology providers to effectively engage patients and family members so that
they deliver the best possible care for patients who undergo lung cancer treatment in the community setting.
C O N C L U S I O N
L U N G C A N C E R T R E AT M E N T I N T H E A A P I C O M M U N I T Y I a c c c - c a n c e r. o r g / l u n g I 1 1
1. Intercultural Cancer Council. Asian Americans and Cancer. Available on-
line at: cancer.org/acs/groups/content/@midwest/documents/document/
acspc-029976.pdf. Last accessed Feb. 25, 2016.
2. Epidemiologic Profi le 2010: Asians and Native Hawaiians and Other
Pacifi c Islanders. Available online at: cdc.gov/nchhstp/publications/docs/
Asian_NHPI_Epi_Profi le2010-20120813_01.pdf. Last accessed Feb. 25,
2016.
3. The White House: Initiative on Asian Americans and Pacifi c Islanders.
Critical Issues Facing Asian Americans and Pacifi c Islanders. Available
online at: whitehouse.gov/administration/eop/aapi/data/critical-issues.
Last accessed Feb. 25, 2016.
4. The White House: Initiative on Asian Americans and Pacifi c Islanders.
Key Facts and Figures on Asian Americans and Pacifi c Islanders. Available
online at: whitehouse.gov/administration/eop/aapi/data/facts-and-fi gures.
Last accessed Feb. 25, 2016.
5. CDC. Health disparities among Native Hawaiians & other Pacifi c Islanders
garner little attention. Chronic Dis Notes Rep. 2002;15(2):14-27.
6. The National Center for Reducing Asian American Cancer Health Disparities.
Asian American Cancer Health Disparities: What is Unnecessary and
Unusual about Asian American Health Disparities? Available online at:
aancart.org/cancer-research/publications/ asian-american-cancer-health-
disparities. Last accessed Feb. 25, 2016.
7. Samet JM, et al. Lung Cancer in Never Smokers: Clinical Epidemiology
and Environmental Risk Factors. Clin Cancer Res. 2009;15(18):5626-5645.
8. Lan Q, et al. Genome-wide association analysis identifi es new lung cancer
susceptibility loci in never-smoking women in Asia. Nature Genetics.
2012;44:1330-1335.
9. National Cancer Institute. Community Networks Program Centers
(CNPC). Available online at: cancer.gov/about-nci/organization/crchd/
disparities-research/cnpc. Last accessed Feb. 25, 2016.
10. American Cancer Society. Road to Recovery Program. Available online at:
cancer.org/treatment/supportprogramsservices/road-to-recovery.
Last accessed Feb. 25, 2016.
11. Wasserman M, et al. Identifying and preventing medical errors in patients
with limited English profi ciency: key fi ndings and tools for the fi eld.
J Health Qual. 2014;36(3):5-16.
12. CMS. CMS Manual, Section 3113: Laboratory Demonstration for Certain
Complex Diagnostic Tests. Available online at: cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/downloads/R70DEMO.pdf.
Last accessed Feb. 25, 2016.
13. D’Angelo SP, et al. Incidence of EGFR exon 19 deletions and L858R in
tumor specimens from men and cigarette smokers with lung
adenocarcinomas. J Clin Oncol. 201;29(15):2066-2070.
14. Wang S, Wang Z. EGFR mutations in patients with non-small cell lung
cancer from mainland China and their relationships with
clinicopathological features: a meta-analysis. Intern J Clin Exper Med.
2014;7(8):1967-1978.
15. Shi Y, et al. A prospective, molecular epidemiology study of EGFR
mutations in Asian Patients with advanced non-small-cell lung cancer
of adenocarcinoma histology (PIONEER). J Thoracic Oncol.
2014;9(2): 154-162.
16. Stewart EL, et al. Known and putative mechanisms of resistance to EGFR
targeted therapies in NSCLC patients with EGFR mutations—a review.
Trans Lung Cancer Research. 2015;4(1):67-81.
17. Simon S, et al. Fallout from nuclear weapons tests and cancer risks.
Amer Scientist. 2006;94(1):48.
R E F E R E N C E S
1 2 I A S S O C I AT I O N O F C O M M U N I T Y C A N C E R C E N T E R S I a c c c - c a n c e r. o r g
A B O U T T H E A S S O C I AT I O N O F C O M M U N I T Y CA N C E R C E N T E R S
T
he Association of Community Cancer Centers (ACCC) is the leading advocacy and education organization for
the multidisciplinary cancer care team. Approximately 20,000 cancer care professionals from 2,000 hospitals
and practices nationwide are affi liated with ACCC. Providing a national forum for addressing issues that affect
community cancer programs, ACCC is recognized as the premier provider of resources for the entire oncology care
team. Our members include medical and radiation oncologists, surgeons, cancer program administrators and
medical directors, senior hospital executives, practice managers, pharmacists, oncology nurses, radiation
therapists, social workers, and cancer program data managers. Not a member? Join today at
accc-cancer.org/membership or email: [email protected]
For more information, visit the ACCC website at accc-cancer.org. Follow us on Facebook, Twitter, LinkedIn,
and read our blog, ACCCBuzz.
©2016. Association of Community Cancer Centers. All rights reserved. No part of this publication may be reproduced or transmitted in any form
or by any means without written …
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