Cancer Databases: Israel De Alba

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  • California is the state that contributes with the greatest number of cervical cancer cases in the country. This is due to its big population and a cervical cancer age-adjusted incidence rate that is greater than the national mean.
  • In California, one of every two residents belongs to a minority group; for instance, one in three State residents is Hispanic and one in nine is Asian. Yet, despite this great ethnic diversity there is limited research on the use of Pap smears by ethnic groups in the state.
  • Aim 1. To assess the impact of race/ethnicity on Pap smear use among women in California
    Aim 2. To examine the effect of ethnic sub-groups on cervical cancer screening among Hispanic and Asian women in California
  • Inclusion criteria:
    Age ≥18
    No hysterectomy
    Outcomes
    Recent Pap smear (in past 3 years)
    Ever having a Pap smear
  • The statistical analyses included six logistic regression models to adjust for potential confounders
    READ
  • Hispanic sub-groups
    Mexican
    Central American
    South American
    Other
    Caribbean Hispanics (Cubans, Puerto Ricans and Dominicans) constitute very small percentages of Hispanics in Califonria
  • Asian Sub-groups
    Japanese
    Filipino
    Korean
    Chinese
    Vietnamese
    South Asians
    (Bangladeshi, Indian, Pakistani, Sri Lankan, and more than one of these nationalities)
  • We adjusted for age, education level, income, having health insurance, self-reported health status and ablility to speak English
  • These are the results for the analysis that included all women; most were young, about half were White, Hispanics constituted 30%, Asians 11% and African Americans only 5%. This race/ethnicity distribution is identical to the one reported in the 2000 Census for the state of California
  • This is the logistic regression results, it is presented in prevalence rate ratios. After adjusting for sociodemographic and access factors, Hispanics and African Americans were significantly more likely to report a Pap smear in the past three years as compared to white women. Asians were significantly less likely to report one as compared to White, Hispanic and African American women
    With regards to ever having a Pap smear, there was no difference among Whites, Hispanics and African Americans, however, Asians were significantly less likely to report a Pap smear ever as compared to these three groups.
  • In the adjusted analysis, Central and South American women were more likely to report having a recent Pap smear as compared to Mexican women, however, the difference was statistically significant between Mexican and Central American. Because of the small number of South Americans, did not result in a significant difference.
    Although Mexican women were less likely to report a Pap smear ever, the difference was not statistically significant
  • These are the adjusted results for Asian women.
    For recent Pap smear, only South Asian women were significantly less likely to report a recent Pap smear as compared to Filipino and Koreans.
    For Pap smear ever, Chinese, Vietnamese and South Asians were signficantly less likely to report one as compared to Filipino and Korean women

Transcript

  • 1. Using CHIS data to explore Cancer screening disparities in California Israel De Alba, MD MPH Center for Health Policy Research Department of Medicine University of California, Irvine
  • 2. Overview Using CHIS data to explore cancer screening racial/ethnic disparities: two examples 1. Pap smear use in California: are closing the racial/ethnic gap? 2. Impact of U.S. citizenship status on cancer screening among immigrant women
  • 3. Background Cervical Cancer Screening in California Nearly 14% of all new cases nationwide are diagnosed in women residing in California The cervical cancer age adjusted incidence rate in the state is above the national average
  • 4. Background Cervical Cancer Screening in California California has one of the largest proportions of minority populations in the country; one in every three state inhabitants is of Hispanic origin and one in nine of Asian descent
  • 5. Background Study Aims Aim 1. To assess the impact of race/ethnicity on Pap smear use among women in California Aim 2. To examine the effect of ethnic sub-groups on cervical cancer screening among Hispanic and Asian women in California
  • 6. Methods Inclusion criteria: 1. Women age ≥18 2. No hysterectomy Outcomes 1. Receipt of recent Pap smear (in past 3 years) 1. Ever having a Pap smear
  • 7. Methods Statistical analysis 1. Descriptive statistics 2. Bivariable analysis 3. Logistic regression 4. Generation of prevalence rate ratios
  • 8. Methods Logistic regression models constructed Population Dependent variable Main independent variable Model 1 All women Recent Pap smear Race/ethnicity Model 2 All women Pap smear ever Race/ethnicity Model 3 Hispanics only Recent Pap smear Hispanic sub-group Model 4 Hispanics only Pap smear ever Hispanic sub-group Model 5 Asians only Recent Pap smear Asian sub-group Model 6 Asians only Pap smear ever Asian sub-group
  • 9. Methods Hispanic sub-groups Mexican Central American South American Other
  • 10. Methods Asian Sub-groups Japanese Filipino Korean Chinese Vietnamese South Asians • (Bangladeshi, Indian, Pakistani, Sri Lankan, and more than one of these nationalities)
  • 11. Methods Adjusting variables in logistic regression Age 18-30, 31-40, 41-50 and ≥51 Educational attainment < high school, high school, > high school Annual household income < 200% FPL or ≥ 200% FPL Health insurance any coverage or no insurance Self-reported health status excellent, very good or good vs. fair or poor Ability to speak English (only among ethnic sub-groups) very well, well, not well and not all
  • 12. Results: all women Demographics (N=25,228) Age distribution 18-30 30% 31-40 25% 41-50 20% ≥51 25% Race/ethnicity: White 50% Hispanic 30% Asian 11% African American 5% Other 4%
  • 13. Results: all women Pap smear use adjusted prevalence rates ratios Recent Pap Pap ever White 1.0 1.0 Hispanic 1.03* .99 Asian .81* .82* African American 1.03* 1.01 Other .96 .98 * ≤ 0.05
  • 14. Results: Hispanic subgroup analysis Pap smear use adjusted prevalence rate ratios Recent Pap Pap ever Mexican 1.0 1.0 Central American 1.06* 1.04 South American 1.07 1.07 Other Hispanic 1.01 .99 * ≤ 0.05
  • 15. Results: Asian subgroup analysis (N=2,625) Pap smear use adjusted prevalence rate ratios Recent Pap Pap Ever Filipino 1.0 1.0 Korean 0.95 0.91 Japanese 0.95 0.84 Chinese 0.95 0.79* Vietnamese 0.93* 0.78* South Asian 0.93* 0.73* * ≤ 0.05
  • 16. Summary In California, Hispanic and African American women are significantly more likely to report having a recent Pap smear as compared to White women and they are as likely to report a Pap smear ever Asians, however, were significantly less likely to report having a Pap smear recently or ever despite a favorable sociodemographic profile
  • 17. Summary Pap smear use rate varied by ethnic subgroup Mexican women were less likely to report recent or ever Pap smear as compared to Central and South Americans
  • 18. Summary Among Asians: • Filipino and Korean women are the most likely to report recent or ever Pap smear • South Asians, Chinese and Vietnamese were least likely to report any of these outcomes
  • 19. Having a usual source of care and income contributes the most to Pap smear use among all women and Asians in California Health insurance and income are the most important contributors to use of Pap smears among Hispanics Summary, other findings
  • 20. Limitations Self-report of receipt and timing of Pap smear Low response rate for 2001 CHIS (63.7%) Non-response bias Generalizability
  • 21. Specific aim To evaluate the relationship between U.S. citizenship status and receipt of Pap smears and mammograms among immigrant women in California.
  • 22. Rationale Non-U.S. citizen immigrants may be disproportionately affected by access and cultural barriers California has a higher percentage of non-U.S. citizens than any other state
  • 23. Outcomes Cervical cancer screening among immigrant women age 18 or older without a hysterectomy: • Pap smear in the past three years • Pap smear ever Breast cancer screening among immigrant women age 40 or older: 3. Mammogram in the past two years 4. Mammogram ever
  • 24. Statistical analysis Multivariable logistic regression model for each outcome Adjusting for: Age Race/ethnicity Educational attainment Annual household income Having health insurance Years in the U.S. Health status English language proficiency
  • 25. Results 6,320 women were included in our analysis of cervical cancer screening; 47% were U.S. citizens 3,828 in the analysis of breast cancer screening; 65% were U.S. citizens
  • 26. Results
  • 27. Results
  • 28. Conclusions Not being a U.S. citizen is a barrier to receiving cervical and breast cancer screening Additional research is needed to explore causal factors for differences in cancer screening rates between citizens and non-U.S. citizens Immigrants, especially those who are not U.S. citizens, should be targeted for improved health care access and appropriate cancer screening.
  • 29. Using CHIS data to explore cancer screening racial/ethnic disparities: overall impressions Positive aspects Data easily available Well designed, standardized questionnaires Excellent “customer service” High proportion of minority populations
  • 30. Using CHIS data to explore cancer screening racial/ethnic disparities: overall impressions Minor comments Low response rate in 2001 CHIS Limitations of a phone survey