1. 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

2. 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.

3. 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.

4. Immigrants in the U.S.

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

7. CA: 27%

15. “… 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.”

16. 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

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

19. Immigrant Status: A Missing Piece in Health Disparities Research

20. 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.  (

21. Dimentions of Health Disparities
Race/Ethnicity
Socioeconomic status
Immigrant status

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

23. 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

24. Cancer in Chinese Americans
Example:
Cancer in Chinese Americans

25. 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.

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

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

30. 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 ( )

31. Top 5 Cancers Among Chinese Americans, 2004-2008

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

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

43. 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

44. 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)

45. 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

46. 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
A Korean Immigrant Family