Cancer Surveillance Among Immigrant Populations Lihua Liu, PhD Los Angeles Cancer Surveillance Program University of Southern California California Cancer Registrars Association Annual Conference, Ontario, CA,11/2/2015

Who Are Immigrants? The U.S. Census Bureau uses the term foreign born to refer to anyone who is not a U.S. citizen at birth. This includes naturalized U.S. citizens, lawful permanent residents (immigrants), temporary migrants (such as foreign students), humanitarian migrants (such as refugees and asylees), and persons illegally present in the United States.

Immigrant Generations The U.S. Census Bureau uses the term generational status to refer to the place of birth of an individual or an individual’s parents. The first generation refers to those who are foreign born. The second generation refers to those with at least one foreign-born parent. The third-or-higher generation includes those with two U.S. native parents.

Immigrants in the U.S.

“Together, the 1st and 2nd generations of immigrants account for one out of four members of the U.S. population.”

CA: 27%

“… integration increases over time, with immigrants becoming more like the native-born with more time in the country, and with the second and third generations becoming more like other native-born Americans than their parents were.”

Immigrant Well-being (increase vs. decline) Educational attainment Occupational distribution Income Residential integration Language ability Living above the poverty line Health Crime Single parent family

Healthy Immigrant Effect On arrival, immigrants are generally healthier than the native-born. But their healthy advantage diminishes along with their U.S. residency.

Immigrant Status: A Missing Piece in Health Disparities Research

The National Cancer Institute (NCI) defines "cancer health disparities" as adverse differences in cancer incidence (new cases), cancer prevalence (all existing cases), cancer death (mortality), cancer survivorship, and burden of cancer or related health conditions that exist among specific population groups in the United States. These population groups may be characterized by age, disability, education, ethnicity, gender, geographic location, income, or race.  (http://www.cancer.gov/about-nci/organization/crchd/cancer-health-disparities-fact-sheet#q1)

Dimentions of Health Disparities Race/Ethnicity Socioeconomic status Immigrant status

Trends of annual age-adjusted (2000 US Standard) incidence rates of invasive breast cancer among women by race/ethnicity, Los Angeles County, CA, 1972-2007

Significance of Health Disparities Identify high risk population Target intervention Evaluate program effectiveness Reduce cancer burden Search for risk factors Generate etiologic hypothese Provide new perspectives for understanding of disease

Cancer in Chinese Americans Example: Cancer in Chinese Americans

History of Chinese migration to U.S. Dates back to 1820s 1850s: Gold Rush, first wave arrived in California 1860s: Central Pacific Railroad recruited labors Chinese Exclusion Act of 1882, result of anti-Chinese racial tension and economic depression Immigration and Nationality Act of 1965, abolished racial discrimination in immigration law, beginning a period of renewed Chinese immigration to the U.S China’s Open Door policy of 1979, resulted in record numbers of government-sponsored young well-educated Chinese students coming to the U.S. for graduate studies throughout 1980s. 1990s and on, increasing numbers of Chinese emigrate to the U.S. through business, investment, family reunification, and a variety of venues, besides education.

Origins of Chinese Americans Mainland China Qing Dynasty (1644-1911) Republic of China (1911-present in Taiwan) People’s Republic of China (1949-present) Taiwan Hong Kong Macau Other parts of the world

Characteristics of Chinese American vary by origin Education Socioeconomic status Dietary habits Cultural practice Acculturation Generation

Data Sources and Methods SEER API cancer database Previously published reports Miller et al (2008) Gomez et al (2013) CI5 series SEER 9 – white (updated to 2012) LACSP – Chinese (updated to 2012) China – Shanghai (1988-2007)

Top 5 Cancers Among Chinese Americans, 2004-2008

Rate Ratios by Cancer Site, SEER, Men, 1998-2002

Rate Ratios by Cancer Site, SEER, Women, 1998-2002

Summary Chinese Americans have different cancer risk profile from whites Excessive risks particularly for nasopharyngeal, liver, and stomach Intermediate risk for most cancers between U.S. whites and Chinese in China Changing risk levels underline the importance of environmental factors in cancer risk Provide opportunities to generate hypothesis for cancer causes and control

The Need for Better Data “This is a longstanding problem, but it has become increasingly critical as immigration to the United States has increased and as immigrants have become dispersed throughout the country.” Collection of birthplace (individual and parental)

Understanding Immigrants Ready for a change, eager to be accepted, lack of guidance for acculturation Unfamiliar with the U.S. health care systems Unaccustomed to individual freedom and self advocacy, used to a group/collective mentality Culturally rooted respect for and reliance on authorities including doctors Difficulties in effective communication with the mainstream care providers/professional

A Korean Immigrant Family iHi Films Produced by USC Immigrant Health Initiative (iHi) and School of Cinematic Arts (SCA) Uses narrative to illustrate the interplay between immigration, culture and health, exposing health challenges among diverse immigrant Americans Aims to raise awareness and facilitate discussions about health issues, needs and intervention strategies among immigrant communities. Publicly available at www.usc.edu/iHi A Korean Immigrant Family