Cervical cancer among Asian subgroups in California, 1990-2004 Janet Bates, MD MPH California Cancer Registry NAACCR Annual Meeting Denver, Colorado June.

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Presentation transcript:

Cervical cancer among Asian subgroups in California, Janet Bates, MD MPH California Cancer Registry NAACCR Annual Meeting Denver, Colorado June 10, 2008

Background National cancer statistics show lower overall cancer rates among Asians in the US Asians have wide variability in countries of origin, immigration history, culture, language, education and SES that influence cancer risk Aggregated cancer statistics for Asians mask important differences among subgroups Limited national cancer data available on Asian subgroups

Asians in California California has largest Asian population of any state 3.7 million Asians = 12% of state population 90% of California Asian population comprised of 6 subgroups: Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese

Study purpose To describe patterns of cervical cancer incidence, mortality, and survival among 6 major Asian subgroups in California

Methods Cervical cancer cases diagnosed among California residents Included all 6 Asian subgroups and non- Hispanic whites (NHW) Variables: –Age (<40, 40-64, 65+ years) –SES quintile (composite census-based measure*) –Stage (local, regional, distant, unknown) –Surgery (none, local, hysterectomy, other) –Radiation (none, any) –Chemotherapy (none, any) *Yost K et al, Cancer Causes & Control, 2001

Methods Cervical cancer incidence rates and trends calculated using SEERstat Cervical cancer survival probabilities (5 and 10 year) calculated using Kaplan-Meier method Multivariate evaluation of survival calculated using Cox proportional hazards modeling, adjusted for stage, age, SES, and treatment factors

Results

Demographic characteristics: age and SES ChineseFilipinoJapan.KoreanS. AsianViet.NHW N ,879 %%%% Age (yrs) **** < SES quintile **** 1 (low) (high) * P for comparison with NHW is significant at < 0.05

Clinical characteristics: stage distribution ChineseFilipinoJapan.KoreanS. AsianViet.NHW N ,879 %%%% Stage * ** Local Regional Distant Unknown * P for comparison with NHW is significant at < 0.05

Clinical characteristics: stage distribution ChineseFilipinoJapan.KoreanS. AsianViet.NHW N ,879 %%%% Stage * ** Local Regional Distant Unknown * P for comparison with NHW is significant at < 0.05 Lowest proportion of cases diagnosed at local stage were found among South Asian, Filipino, and Korean women; stage distribution among South Asian women not significantly different from NHW

Cervical cancer incidence trends:

Vietnamese had highest incidence throughout period, as well as most dramatic decline

Cervical cancer incidence trends: …followed by Korean, then Filipino women

Cervical cancer incidence trends: Chinese women and NHW had comparable rates in …

Cervical cancer incidence trends: …but by incidence rates were lower among Chinese women NHW Chinese

Cervical cancer incidence trends: Rates among Japanese and South Asian women also declined, but trend not statistically significant Japanese South Asian

Unadjusted cause-specific 5- and 10-year cervical cancer survival Survival probability (%) (95% Confidence Interval) ChineseFilipinoJapaneseKoreanS. AsianViet.NHW 5-year78.6 (74.4, 82.2) 79.0 (75.9, 81.9) 72.3 (64.9, 78.4) 85.7 (80.9, 89.6) 85.8 (75.1, 92.2) 0.79 (0.64, 1.00) 77.5 (76.7, 78.3) 10-year77.2 (72.9, 81.0) 74.8 (71.2, 78.0) 69.5 (61.7, 76.1) 82.5 (77.1, 86.7) 85.8 (75.1, 92.2) 79.7 (75.4, 83.3) 75.4 (74.6, 76.3)

Unadjusted cause-specific cervical cancer survival

Clinical characteristics: stage distribution ChineseFilipinoJapan.KoreanS. AsianViet.NHW N ,879 %%%% Stage * ** Local Regional Distant Unknown * P for comparison with NHW is significant at < 0.05 Lowest proportion of cases diagnosed at local stage were found among South Asian, Filipino, and Korean women; stage distribution among South Asian women not significantly different from NHW

Risk of death due to cervical cancer among Asian subgroups Hazard Ratio (95% Confidence Interval) ChineseFilipinoJapaneseKoreanS. AsianViet. Race only 0.94 (0.78, 1.15) 0.97 (0.83, 1.13) 1.28 (0.97, 1.69) 0.61 (0.45, 0.81) 0.57 (0.32, 1.04) 0.79 (0.64, 1.00) Referent group is Non-Hispanic Whites

Risk of death due to cervical cancer among Asian subgroups Hazard Ratio (95% Confidence Interval) ChineseFilipinoJapaneseKoreanS. AsianViet. Race only 0.94 (0.78, 1.15) 0.97 (0.83, 1.13) 1.28 (0.97, 1.69) 0.61 (0.45, 0.81) 0.57 (0.32, 1.04) 0.79 (0.64, 1.00) Stage0.97 (0.79, 1.18) 0.84 (0.72, 0.98) 1.19 (0.90, 1.56) 0.49 (0.37, 0.66) 0.37 (0.20, 0.66) 0.83 (0.676, 1.03) Referent group is non-Hispanic whites

Risk of death due to cervical cancer among Asian subgroups Hazard Ratio (95% Confidence Interval) ChineseFilipinoJapaneseKoreanS. AsianViet. Race only 0.94 (0.78, 1.15) 0.97 (0.83, 1.13) 1.28 (0.97, 1.69) 0.61 (0.45, 0.81) 0.57 (0.32, 1.04) 0.79 (0.64, 1.00) Stage0.97 (0.79, 1.18) 0.84 (0.72, 0.98) 1.19 (0.90, 1.56) 0.49 (0.37, 0.66) 0.37 (0.20, 0.66) 0.83 (0.676, 1.03) Stage, age 0.89 (0.72, 1.09) 0.82 (0.70, 0.95) 1.15 (0.87, 1.52) 0.47 (0.35, 0.62) 0.34 (0.19, 0.62) 0.79 (0.64, 0.98) Referent group is non-Hispanic whites

Risk of death due to cervical cancer among Asian subgroups ChineseFilipinoJapaneseKoreanS. AsianViet. Race only 0.94 (0.78, 1.15) 0.97 (0.83, 1.13) 1.28 (0.97, 1.69) 0.61 (0.45, 0.81) 0.57 (0.32, 1.04) 0.79 (0.64, 1.00) Stage0.97 (0.79, 1.18) 0.84 (0.72, 0.98) 1.19 (0.90, 1.56) 0.49 (0.37, 0.66) 0.37 (0.20, 0.66) 0.83 (0.676, 1.03) Stage, age 0.89 (0.72, 1.09) 0.82 (0.70, 0.95) 1.15 (0.87, 1.52) 0.47 (0.35, 0.62) 0.34 (0.19, 0.62) 0.79 (0.64, 0.98) Stage, age, Rx, SES 0.83 (0.68, 1.02) 0.78 (0.67, 0.91) 1.13 (0.86, 1.50) 0.42 (0.31, 0.57) 0.31 (0.17, 0.56) 0.77 (0.62, 0.96) Referent group is non-Hispanic whites

Discussion Higher incidence among Vietnamese, Korean, Filipino women mirror international patterns South Asian rates relatively low despite high rates in countries of origin

Discussion Variability in cervical cancer incidence is largely attributed to screening Expect populations with low screening to have higher incidence Examined cervical cancer screening survey data from the California Health Interview Survey (CHIS)

Percent pap test in past 3 years by Asian subgroup, California Source: California Health Interview Survey 2003

Percent pap test in past 3 years and cervical cancer incidence by Asian subgroup, California Source: California Health Interview Survey 2003

Limitations Limited number of cases in some subgroups Misclassification of race is possible Risk factor data (HPV subtypes, smoking, diet, co-morbidities, immigration data, etc.) not available

Summary Distinct variations among subgroups in patterns of cervical cancer incidence and survival Practice of aggregating statistics for Asians masks these differences Public health programs targeting cervical cancer screening and prevention must take these differences into account

Summary Lower risk of cervical cancer death among Vietnamese, Korean, Filipino, and South Asian women Few studies on this Further evaluation of reasons for this apparent survival advantage is needed

Acknowledgements Co-authors: Brenda Hofer, Arti Parikh- Patel CDC Cancer supplement coordinators: Meg Watson, Mona Saraiya CCR research and surveillance program staff: Mark Allen, Allyn Fernandez Ami, Sandy Kwong