Aetna Presentation Cancer

Cancer and U.S. Latinos

Daniel Santibanez, MPH

Department of Public Health

University of North Florida

This is part 5 of an 8 part series of seminars on Hispanic Health Issues brought to you by the University of North Florida’s Dept. of Public Health, College of Health, a grant from AETNA, and the cooperation of

Duval County Health Department. For more information or register for the seminars, please call 620-1289.

Objectives

• Review cancer status among U.S. Hispanics/Latinos

• Review incidence and death rates for specific cancers

• Discuss cancer risk factors

• Discuss access to cancer screenings and care

• Review community interventions, initiatives, and programs

Source: ACS: Cancer Facts & Figures For Hispanic/Latinos 2003-2005

Introduction

• In 2002, ~37.4 million Hispanics comprised about 13.3% of total population

• Hispanics/Latinos are the nation’s fasting growing population

• Within the U.S., different subgroups tend to live in certain regions

• Cancer occurrence can vary across these groups because of regional, behavioral, or genetic differences

• Furthermore, Hispanics’ risk of cancer can differ based on whether they are U.S. born or foreign-born, country of origin or heritage, degree of acculturation, and socioeconomic status


Introduction• Cancer is a group of diseases characterized by

uncontrolled growth and spread of abnormal cells

• Among Latino adults, cancer is the second leading cause of death, following health disease

• For most cancer sites, incidence and death rates among people of Hispanic origin are lower than among non-Hispanics

• For cancers of the stomach, liver, and cervix, rates are higher in Hispanics than in non-Hispanic whites


Acculturation and Cancer

• Americans of Hispanic descent experience a cancer burden similar to that seen in countries from which they emigrated

• Compared to rates in the U.S., the incidence rates of breast, colon and rectum, lung, and prostate cancers are lower in Puerto Rico, Cuba, and Central and South American countries than in the U.S.

• BUT, rates of cervical, liver, and stomach cancers are higher.

• There is some evidence that among Hispanics who migrated, subsequent generations have cancer rates which approach the rates of non-Hispanics

Source: National Cancer Institute: Cancer Health Disparities

Cancer Incidence Rates(Number of new cases each year)

Group Both Sexes Males Females

African-American 521.7 696.8 406.3

White 479.8 555.9 431.8

Hispanic/Latino 352.1 419.3 312.2

Asian/Pacific Islander 341.7 392.0 306.9

Amer Indian/ Alaska Native 239.6 259.0 229.2

Statistics are for 1996-2000, are adjusted for the 2000 U.S. standard million population, and represent the number of new cases of invasive cancer per year per 100,000 of both sexes, males, and females, respectively.


Cancer Death Rates(Number of deaths each year)

Group Both Sexes Males Females

African-American 257.1 356.2 198.6

White 199.1 249.5 166.9

Amer Indian/ Alaska Native 138.0 172.3 115.8

Hispanic/Latino 137.9 176.7 112.4

Asian/Pacific Islander 124.5 154.8 102.0

Statistics are for 1996-2000, are adjusted for the 2000 U.S. standard million population, and represent the number of deaths per year per 100,000 of both sexes, males, and females, respectively.


Female Breast Cancer

• Breast cancer is the most commonly diagnosed cancer among Hispanic women

• Rate of new cases diagnosed among Latinas during 1992-1999 remained stable, while non-Hispanic women showed an annual increase of 1.3%

• Although breast cancer is diagnosed ~40% less often among women of Hispanic origin, it is more frequently diagnosed at a later stage than when found in non-Hispanic women

• Historically lower utilization of cancer screening tests, such as mammography, among Latinas may contribute to later diagnosis, when the disease is more advanced


Hispanic/Latina Females: Death Rates and Incidence for Breast

Cancer

Statistics are for 1996-2000, are adjusted for the 2000 U.S. standard million population, and represent the number of deaths or new cases of invasive cancer, respectively per year per 100,000 females.

Group Breast--Female Death

Breast --Female Incidence

African-American 35.9 121.7

White 27.2 140.8

Hispanic/Latina 17.9 89.8

Amer Indian/Alaska Nat 14.9 58.0

Asian/Pacific Islander 12.5 97.2


Cancer of the Lung & Bronchus•New Cases:

•Cancer of the lung is the fourth most commonly diagnosed cancer among Hispanic men and women combined

•Because of traditionally lower rates of cigarette smoking among Hispanics, lung cancer rates were ~50% lower than those in non-Hispanics between 1992-1999

•Deaths:

•Lung cancer is the leading cause of cancer death among Hispanic men

•It ranks second among Hispanic women

•Death rates from lung cancer have been declining among men due to decreases in the prevalence of smoking


Hispanic/Latino Males: Incidence and Death Rates for

Lung Cancer


Group Lung and Bronchus--Male Incidence

Lung and Bronchus--Male Death


White 79.4 78.1





Hispanic/Latina Females: Incidence and Death Rates for

Lung Cancer


Group Lung and Bronchus--Female Incidence

Lung and Bronchus--Female Death


White 51.9 41.5




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Cancer of the Prostate•New Cases:

•Prostate cancer is the most commonly diagnosed cancer among Hispanic men

•During 1992-99, rates were approximately 25% lower than the rates among non-Hispanics

•Among Hispanics, an annual average decrease of 3.4% was seen, compared to 4.6% among non-Hispanic whites

•Deaths:

•Prostate is the second leading cause of cancer death among men

•The same number of deaths occur from prostate and colorectal cancers

•The death rate dropped 3.8% per year on average in Hispanic men, compared to an average annual decrease of 3.5% in white non-Hispanics


Hispanic/Latino Males: Incidence and Death Rates for

Prostate Cancer

Statistics are for 1996-2000, are adjusted for the 2000 U.S. standard million population, and represent the number of new cases of invasive cancer per year per 100,000 males.

Group Prostate--Incidence Prostate--Death


White 164.3 30.2

Hispanic/Latino 137.2 24.1


Amer Indian/ Alaska Native 53.6 21.9

Hispanic/Latino males have the third highest incidence and death rates for prostate cancer after African-Americans and whites.


Cancer of the Colon and Rectum

• Colorectal cancer is the third most diagnosed cancer in Hispanics

• During 1992-1999 colorectal rates did not significantly change

• Colorectal cancer is the third leading cause of cancer death among Hispanic women

• It ties with prostate cancer as the second deadliest cancer among Hispanic men

• The death rates due to colorectal cancer in Hispanic men and women declined on average 0.7% each year during 1992-1999; compared with a 1.8% annual decline for non-Hispanic white


Hispanic/Latino Males: Incidence & Death Rates for

Colorectal Cancer


Group Colon and Rectum--Male Incidence

Colon and Rectum--Male Death


White 64.1 25.3





Hispanic/Latina Females: Incidence & Death Rates for

Colorectal Cancer


Group Colon and Rectum--Female Incidence

Colon and Rectum--Female Death


White 46.2 17.5





While Hispanics/Latinos have lower incidence and death rates overall compared with those of African-Americans and whites, they do experience higher rates for certain cancers.


Cancer Sites with Higher Rates in Hispanics

• Cancers of the stomach, liver, and uterine cervix are more common in developing countries

• Most notably in Central and South American countries

• In the U.S., the incidence and mortality rates of stomach, uterine cervix, liver and biliary tract cancers are higher among Hispanics than non-Hispanics whites

• They are especially higher among first generation migrants to the U.S.


Cancer of the Stomach

• Stomach cancer is most prevalent throughout much of Central and South America than in the U.S.

• Diets rich in smoked fish, salted meat or fish, and pickled vegetables and low in fresh vegetables have been associated with an increased risk

• Another risk factor, H.pylori, is more common among those of lower SES, particularly if they live in crowded or high-density living conditions

• In the U.S., the rates of stomach cancer incidence are at least 75% higher in Hispanics than in non-Hispanic whites


Liver and Intrahepatic Bile Duct Cancer

• Liver cancer is strongly associated with chronic infections from hepatitis B virus (HBV) or hepatitis C virus (HCV)

• HBV is preventable through vaccination, but there is yet no vaccine for HCV

• Alcohol intake and consumption of aflatoxin-contaminated grains are also risk factors

• Hispanics experience a 60% higher death rate from liver cancer compared with non-Hispanics


Hispanic/Latino Both Sexes: Incidence Rates for Liver and Stomach

Cancer


Group Liver--Incidence Stomach--Incidence





White 4.8 7.7


Cancer of the Cervix

• Women in Mexico, Central America, and South America experience approx. triple the cervical cancer incidence and mortality rates of women in the U.S.

• Hispanic women residing in the U.S. have twice the cervical cancer incidence rate of non-Hispanic whites

• Certain variants of human papilloma virus (HPV) are associated with increased risk

• Among U.S. women, those born in Mexico have higher prevalence of HPV

• The death rate from cervical cancer is 40% higher among Hispanic women than among other groups


Hispanic/Latina Females: Highest Incidence Rates for Cervical

Cancer

Group Cervix Uteri--Incidence

Hispanic/Latino 16.8

African-American 12.4

Asian/Pacific Islander 10.2

White 9.2

Amer Indian/ Alaska Native 6.4

Statistics are for 1996-2000, are adjusted for the 2000 U.S. standard million population, and represent the number of new cases of invasive cancer per year per 100,000 females.


Hispanic/Latina Females: Cervical Cancer Death Rates

Group Cervix Uteri--Death

African-American 5.9

Hispanic/Latino 3.7

Amer Indian/ Alaska Native 2.9

Asian/ Pacific Islander 2.9

White 2.7

Statistics are for 1996-2000, are adjusted for the 2000 U.S. standard million population, and represent the number of deaths per year per 100,000 females.

Despite high incidence rates, Hispanic/Latina females have the second highest death rate for cervical cancer; African-American females have the highest.


Cancer of the Gallbladder• Worldwide, the highest incidence rates of gallbladder

cancer are found among Mexican-Americans

• The highest mortality rates are in South America

• Among those populations with elevated rates, women are diagnosed more often than men

• An important risk factor for gallbladder cancer is chronic gallstones which can result from hereditary factors affecting cholesterol secretion in the bile

• This genetic susceptibility may be more common among Hispanics

• Obesity, hormonal factors, and diet may be associated with increased risk of gallbladder cancer

• In the U.S., Hispanic females experience over twice the incidence rates of non-Hispanic white women and Hispanic men


Gallbladder Cancer:Incidence Rates and Ratios*, 1995-

1999

Male Female

Hispanic Non-Hisp Ratio Hispanic Non-Hisp Ratio

Gallbladder 1.2 0.8 1.5 3.4 1.3 2.6

*Ratios calculated as Hispanic incidence divided by non-Hispanic incidence

Age-adjusted to the year 2000 population standards.


Gallbladder Cancer:Mortality Rates and Ratios*, 1995-

1999

Male Female

Hispanic Non-Hisp Ratio Hispanic Non-Hisp Ratio

Gallbladder 0.7 0.5 1.4 1.7 0.9 1.9

*Ratios calculated as Hispanic mortality divided by non-Hispanic mortality

Age-adjusted to the year 2000 population standards.


Cancer Risk Factors

Variations in cancer risk factors or screening behaviors between Hispanics and other population groups may be due to cultural differences or socioeconomic factors


Tobacco Use• Tobacco use is the most preventable cause of

premature death in the U.S. and is responsible for 30% of all cancer deaths

• In 2001, 16% of Hispanic adults were identified as current smokers compared to 22.8% of all adults

• The percentage of Hispanic smokers has decreased since 1978 with small recent increases in males

• Further reduction of smoking prevalence among Hispanics requires an understanding of the cultural, ethnic, and social issues


Tobacco Use

• Members of lower SES groups are more likely smoke

• One-fifth of Hispanics live in poverty, which is almost twice the national poverty rate

• Smoking during pregnancy is less prevalent among Latinas

• Hispanics born in the U.S. were more likely to smoke than those who are foreign-born

• Members of racial/ethnic groups are less likely than whites to participate in cessation programs or to receive advice on quitting from providers

• For smoking cessation classes to be successful among Hispanics, they should be language appropriate, considerate of cultural values, and mindful of potential pressures facing Hispanics


Hispanic/Latino Youth Tobacco Use• It is estimated that among current adult cigarette

smokers, over 80% began smoking before they reached age 18

• In 2001, according to Youth Risk Behavior Surveillance System (YRBSS), 26.0% of Hispanic females and 27.2% Hispanic males admitted to being current smokers

• Factors influencing the differing smoking habits may include basic cultural differences as well as differences in the affordability and accessibility of cigarettes

• Hispanics who do not complete a high school education are more likely to smoke than their more educated peers

• Adolescent Hispanic females are less likely to smoke if they have the advantage of a strong and supportive family network


Overweight, Obesity, and Physical Activity

• Obesity is associated with an increased risk of several chronic diseases, including cancers of the endometrium, breast, prostate, and colon

• An estimated 22.9% of adults in the U.S. are obese

• Obesity is on the rise among Hispanics, particularly for Hispanic women

• Studies have shown that participation in regular physical activity helps to control body weight and may decrease the risk of colon and breast cancers

• In 2001, 35.8% of Hispanic adults did not have any form of leisure time physical activity compared to 22.9% of non-Hispanic whites


Use of Screening Tests

• Hispanic women are traditionally the least likely of racial and ethnic groups to use preventive services such as pap tests, mammography, and clinical breast exams

• Underuse of these tests may contribute to poorer survival for cervical and breast cancer

• Continuation of social support programs which specifically target minority populations may further improve participation in screening examinations

• Improvements in the healthcare system are needed- almost 1/3 of all Hispanics have no health insurance greatly limiting their access to cancer screening and medical care


Cancer Screening Examinations, Adults, 2000-2001

% Hispanic % White, non-Hisp

%Black,

non-Hisp

Breast Cancer,2000

Mammogram 65.4 62.9 66.7

Clinical breast exam 65.1 68.8 69.9

Mammogram & CBE 53.5 56.0 54.8

Cervical Cancer, 2000

Pap Test 83.4 87.2 88.8

Colon & Rectum Cancer, 2000

Fecal Occult Blood Test 15.4 24.1 21.6

Flexible Sigmoidoscopy or colonoscopy 31.2 39.2 35.3

Prostate Cancer, 2000

Prostate-specific antigen test 46.0 58.2 57.6

Digital rectal exam 41.4 57.4 49.5

Redes en Accion: Latino Cancer Report

Access to Cancer Screening and Care

• Hispanics/Latinos tend to underutilize cancer screening procedure for several reasons:

• Lack of knowledge about the different types of cancer and tests for their presence

• Fatalism about the efficacy of treatment if cancer is present

• In one study of urban Latinas, perceptions that “not much can de done” about breast cancer correlated with lower mammography rates


Tobacco Use and Cancer

“The need for a culturally appropriate smoking-cessation intervention for Latinos is based on data on current patterns of tobacco use, possible targeting by the tobacco industry, and the lack of smoking-cessation interventions that are appropriate to the cultural characteristics of Latino smokers”

Programma Latino Para Dejar de Fumar initiative in San Francisco


Status and Communication of Cancer Risk

• Hispanics/Latinos show great variation in perceptions of cancer incidence and mortality risk

• Latinas tended to link cancer incidence to stress and trauma to the body and behavior choices

In one study, Latinas (56% Mexican-American) were more likely than Anglo women to view “sugar substitutes, bruises, microwave ovens, spicy foods, breast-feeding, and antibodies” as causes of cancer. Perez-Stable EJ, etal. JAMA. 1992; 268:3219-3223


Occupational and Environmental Risk

• While there is extensive data on the relationships between specific toxins and rare cancers, the risk profile for Hispanics/Latinos is not well-documented

• SES more connected to environmental risks than ethnicity

• Migrant workers have higher rates of certain types of cancer, such as leukemia and stomach, cervical, uterine cancer, and certain oral and throat cancer and cancer of the skin


Cancer Survivorship and Health-Related Quality of Life

Clinical Variables that affect survival:

•Time of diagnosis

•Effectiveness of treatment

Psychosocial variables:

•Amount of life stress

•Educational attainment

•Income level

•Partnership status

•Existence of co-morbid conditions

Religious faith, family support, support groups, and dietary therapies are some strategies identified as increasing quality of life among Hispanics/Latinos.


Patient-Clinician Communication

• Various barriers hinder communication between Hispanic patients and clinicians

• Language and cultural barriers are the most prominent

• Negative physician attitudes towards Latinos and difficulty in getting referrals to specialists also pose barriers


Education, Training, and Outreach

For non-Latino providers, being able to speak Spanish and having an understanding of Latino culture and subcultures are important skills in screening, diagnosing, and treating Hispanic/Latino patients, although effective interpreter programs may fill in the gap.

Clinical Trials Education Series• La Historia de Jose y La Historia de Ana • A fotonovela-style introductory Spanish-language

presentation that takes you on a journey of Jose, a man who is given the option of enrolling in a prevention clinical trial.

• Ana’s journey follows a women who is given the option of enrolling in a treatment clinical trial.

• Conversemos un rato• A Spanish-language slide presentation that

covers the basics about clinical trials. Appropriate for community leaders and health care providers

http://www.cancer.gov/

Cervical Cancer Program

“Combining and linking a multicultural mass media campaign, outreach efforts, and a multilingual hotline with community-based outreach programs created maximal effect and increased the likelihood that women would seek recommended screening.”

National Latino Council on Alcohol and Tobacco Prevention• Created by the Office on Smoking and Health of the CDC

to accomplish several goals:

• Create a national Hispanic/Latino tobacco prevention and control network

• Increase the ability of Hispanic/Latino organizations to mobilize their constituents to address and support prevention efforts

• Identify ways to reach Hispanic/Latino organizations with culturally appropriate prevention and control efforts

• Initiate and expand initiatives to educate network members and the public

• Initiate and expand effective tobacco prevention and control measures in the U.S. Hispanic/Latino community

!Celebremos la Vida! Let’s Celebrate Life

• !Celebremos la Vida! is a long-standing breast and cervical cancer education, screening and early detection program for medically underserved Latinas over the age of 40 in Washington, D.C., Northern Virginia, and McHenry County, Illinois.

• Conducted in Spanish, screenings are coupled with an intensive educational program that emphasizes the role of prevention and early detection through regular practice of breast self-exams, clinical breast exams, mammograms, pelvic exams and Pap tests.

En Accion uses 5 approaches:

Research

Demonstration

Dissemination

EvaluationPolicy

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•Thank You!

•Any questions?

Daniel [email protected]

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