Essays /

Cancer Among Asian Indianspakistanis Living In Essay

Essay preview

Cancer Causes Control (2009) 20:635–643
DOI 10.1007/s10552-008-9275-x

ORIGINAL PAPER

Cancer among Asian Indians/Pakistanis living in the United
States: low incidence and generally above average survival
William B. Goggins Æ Grace Wong

Received: 1 August 2007 / Accepted: 19 November 2008 / Published online: 6 December 2008 Ó Springer Science+Business Media B.V. 2008

Abstract
Background South Asian immigrants living in the United
Kingdom and Canada have been found to have lower rates
of cancers of all types compared with the native born
population and most other immigrant groups. Cancer
among Asian Indian/Pakistani people in the United States
has been studied very little.
Methods Incidence rates for all cancers combined and
site-specific rates for major cancers were estimated for
Asian Indians/Pakistani population using incidence data
from the U.S. National Cancer Institutes SEER database
and population data from the U.S. Census Bureau. Sitespecific survival was compared for major cancer sites between Asian Indians/Pakistanis and Caucasians using
Cox proportional hazards models.
Results Cancer rates for Asian Indian/Pakistani males and
females were considerably lower than for White Americans
with standardized incidence ratios (SIRs) of 0.46 (95%
CI = 0.44, 0.48), and 0.55 (95% CI = 0.53, 0.58) respectively. Site-specific rates were lower for both genders for most sites with particularly low rates observed for lung,
colorectal, female breast, and prostate cancer. Among
common cancers sites, survival was generally better among
Asian Indians/Pakistanis than Caucasians with the notable
exception of breast cancer for which Caucasians had slightly better survival.

W. B. Goggins (&) Á G. Wong
School of Public Health, Chinese University
of Hong Kong, Room 501, Shatin, Hong Kong
e-mail: [email protected]
W. B. Goggins
Nethersole School of Nursing, Chinese University
of Hong Kong, Shatin, Hong Kong

Conclusions The finding that Asian Indians/Pakistanis in
the United States have relatively low incidence rates for
most major cancers is consistent with studies from other
countries. Whether the low incidence of cancer and above
average cancer survival for this group is related to their
well-above average socioeconomic status or cultural and
behavioral factors is a topic for further research.
Keywords
Inequality

SEER Á Ethnic Á Race Á South Asian Á

Introduction
Considerable ethnic variation in the incidence and survival
rates for many types of cancers have been reported from
the United States and other countries. One group whose
cancer experience has been little studied in the United
States are Asian Indians, a mostly affluent, and well-educated group whose numbers have been rapidly increasing in recent years.
Previous studies have shown that cancer rates for South
Asians are generally lower than those of the non-South
Asian population of that country but higher than those of the Indian subcontinent. A study using data from the California
cancer registry found that South Asians, of whom about 90%
were Asian Indians, had lower cancer incidence than nonHispanic whites for most sites, but higher incidence than Whites for liver cancer for both genders, and stomach,
esophageal, and cervical cancer for females [1]. A registrybased study from the United Kingdom [2] found that South Asians had substantially lower incidence rates for most
major cancers than non-South Asians. A Canadian study [3]
found that cancer mortality rates among South Asians were
lower than those of both White and Chinese Canadians. Data

123

636

from Singapore indicate that Indians there recently have
lower cancer incidence than either Chinese or Malays [4],
whereas incidence rates for Indians in Malaysia are
lower than those for Chinese but higher than those for
Malays [5].
A study of female breast cancer survival using U.S.
cancer registry data found that Asian Indian/Pakistani
women had non-significantly worse overall survival than
non-Hispanic Whites after adjustment for demographic
variables only, but that they had non-significantly better
survival after additional adjustment for disease characteristics [6]. Two studies from the United Kingdom [7, 8] have found that South Asian women, and another found
that they had about the same survival rate [9]. A study of
colorectal cancer survival using U.S. cancer registry data
found that Asian Indians/Pakistanis had significantly better survival compared with Whites [10].
In this article, we present findings on cancer incidence
and survival on this group using data from the U.S.
National Cancer Institute’s (NCI) Surveillance Epidemiology and End Results (SEER) program. Because Asian Indians and Pakistanis are included as one category in
the SEER data these groups are analyzed together.
However, as about 94% of the Asian Indian/Pakistani
population of the relevant SEER areas is Asian Indian,
the inferences drawn from this study mostly apply to this
group.

Methods
Incidence
Incidence rates for cancers for Asian Indians/Pakistanis
were estimated using data from the seven SEER registries
with the largest populations for these groups: the state of
Connecticut, and the cities of San Francisco, San Jose, Los
Angeles, Detroit, Seattle, and Atlanta. The gender- and
age-specific counts of malignant neoplasms during 1988 to
2004 were obtained using SEER’s SEERStat 6.3.5 program. The number of person-years was estimated using data from the U.S. Census bureau. First, the Asian Indian
and Pakistani populations for the relevant SEER areas were
obtained for 1990–2000, and then linear interpolation was
used to estimate the number of person-years. This method
assumes that the population change for the period from
1988 to 2004 was constant, and the yearly rate of population change was equal to the difference between the 2000 and 1990 populations divided by 10. Gender- and agespecific rates for cancer overall and for common sites were then calculated as cases divided by person-years. Agestandardized rates (ASR) were estimated using the world standard population, and standardized incidence ratios

123

Cancer Causes Control (2009) 20:635–643

(SIRs) comparing the rates for South Asians against rates
for Whites were then calculated in the standard fashion
using the standard method [11]. Confidence intervals (CIs)
for the SIRs were calculated using the ‘‘errors-in-variables’’ approach [12] because the reference rates and person-years used were not exact. The reference rates for
Whites were calculated using data from the same six registries only. ASRs for the Indian registries in Bombay and Madras were obtained from the IARC’s Cancer Mondial
Statistical Information System [13].
Survival
Data from all the 17 SEER registries were used for the
survival comparisons. Analysis was restricted to 1988–2004 because Asian Indians/Pakistanis were classified as ‘‘Other Asians’’ before 1988. Site-specific survival was analyzed for cancers of the colon, rectum, stomach, esophagus, pancreas,

liver, lung and bronchus, prostate, female breast, ovaries,
brain, and non-Hodgkin’s lymphoma (NHL). Cox proportional hazards models were used to estimate relative risks (RRs) and their 95% CIs for all-cause and cause-specific
mortality for each of the above sites after adjusting for
relevant confounders. For the cause-specific mortality
analyses only deaths from cancer of the site being analyzed
were the considered events, and subjects were considered
censored at time of death if they had died of other causes.
Relative risks were estimated for South Asians and Chinese
with non-Hispanic Whites serving as the reference group.
Results for Chinese, another recent immigrant group with an
above-average SES profile, were included for comparison
purposes. The proportional hazards assumption was verified
by visual examination of Kaplan–Meier survival plots. The
correct functional form for continuous covariates, age and
year of diagnosis, was determined by examining scatterplots
of Martingale residuals from Cox models fit omitting the
relevant covariate vs. that covariate [14]. Two models were
fit for each type of mortality, one adjusting only for demographic factors including age (using linear and quadratic...

Read more

Keywords

-0142 -7 /1477-3163-4-21 /978-0387-46401-5_5 /archinte.163.1.49 /b /biomet/77.1.147 /chest.07-0442 /cncr.21204 /data/hpb. /ije/24.3.504 /j /j.cdp.2005.06.013 /j.ejca.2008 /jech.2004.030965 /publications/documents/ /s10552-008-9275-x /s15327914nc5502_2 /servlet/dtgeosearchbylistservlet? /servlet/safff /sj.bjc.66 /sj.bjc.6601097 /sj.bjc.6690102 /strategy/downloads/ 0.05 0.15 0.16 0.20 0.25 0.26 0.29 0.30 0.31 0.32 0.33 0.34 0.36 0.37 0.39 0.40 0.41 0.42 0.44 0.45 0.46 0.47 0.48 0.49 0.5 0.50 0.51 0.52 0.53 0.54 0.55 0.56 0.57 0.58 0.59 0.60 0.61 0.62 0.63 0.65 0.66 0.67 0.68 0.69 0.70 0.72 0.73 0.74 0.75 0.76 0.77 0.79 0.8 0.80 0.81 0.82 0.83 0.84 0.86 0.87 0.9 0.91 0.92 0.94 0.95 0.97 0001 0002 0003 0004 0005 0006 0007 001 002 003 005 006 007 008 015 01795 029 03 032 033 038 04.002 045 046 047 076 079 08 080 09 093 1 1.0 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.1 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.2 1.20 1.22 1.24 1.25 1.26 1.27 1.28 1.29 1.3 1.30 1.32 1.34 1.37 1.4 1.43 1.46 1.47 1.48 1.52 1.57 1.58 1.6 1.60 1.63 1.65 1.66 1.7 1.71 1.76 1.77 1.78 1.81 1.88 1.9 1.90 1.96 10 10.1001 10.1002 10.1007 10.1016 10.1023 10.1038 10.1093 10.1111 10.1136 10.1186 10.1207 10.1378 10.3 10.4 10.57 10.7 104 106 106.4 108 1097 11 11.1 116 116.6 117.4 12 12.3 12.65 123 124.7 126 127 13 13.6 13.8 131 132 138 14 141 146 147 149 1497.2005.40294 15 15.1 15.50 1525 156 1566 1571 16 16.07 160 161 163 166.25 169 17 17.5 172 173 18 184.88 185 19 19.2 191 192 1926 1932 194 1968 1979 1985 1987 1988 1990 1991 1992 1993 1994 1995 1997 1999 2 2.0 2.14 2.2 2.20 2.24 2.3 2.32 2.35 2.39 2.4 2.41 2.44 2.48 2.5 2.61 2.7 2.8 2.88 2.9 2.93 20 2000 20000801 2001 2002 2003 2004 2005 2006 2007 2008 2009 201676568406 202 207 21 21.9 210 214 22 22.8 226 23 23.7 231 238 24 241 243817643062 25 26 27 28 29 29.9 3 3.0 3.0.co 3.01 3.29 3.3 3.4 3.48 3.5 3.52 3.6 3.60 3.9 3.96 30 30.1 30.3 31 313 317 32 321 33 33.7 34 35 35.4 358 36 36.4 37 370 379 38 38.6 380 39 4 4.0 4.1 4.16 4.43 4.6 4.7 4.77 4.8 4.85 4.9 40 402 406 41 412 416 42 42.4 43.8 44 444 45 45.4 454 46 46.0 46.8 466 47 474 478 48 482 49 49.1 49.8 5 5.0 5.08 5.4 5.6 5.7 5.76 50 50.5 501 504 508 51 512 514 52 53 54 55 55.7 550 557 56 57 58 59 59.52 595 6 6.03 6.2 6.20 6.3.5 6.4 6.5 6.7 6.73 6.77 6.8 60 62 629 63 63.5 63.72 635 636 637 638 639 64 640 641 642 643 645 65 652 654 66 66.6 665 669 67 68 687 69 696 7 7.2 7.4 7.8 7.84 70 701 705 71 711 72 73 732 74 75 752 76 77 78 783 79 791 8 8.5 80 805 81 818 82 83 84 85 850 86 87 88 89 9 9.00 9.19 9.60 9.75 90 91 92 923 93 94 95 96 97 98 99 above-averag abstract accept access accord accultur accur acknowledg actschariter acut addit adenocarcinoma adenoma adjust adult adv advanc advantag affluent age age-specif age-standard age2 agespecif agestandard aid aid-cncr27 aj al al-delaimi all-caus allcaus almost also although alway american among amount analys analysi analyz anand ancestri angel anim anoth appar appear appli approach appropri april arch area around articl asian asian-american asian-indian asian/pacific asianamerican asr associ assum assumpt atlanta attenu attribut august author averag avoid b b-cell b.v background bangladesh bangladeshi base becam becom begin behavior belief bell better better-than-averag bhakta bias biol biometrika bl bladder bombay booth bor born br brain breast breslow bronchus bryant bureau busi c cabinet caco.0000043431.85706.d8 calcul california canada canadian cancer cancerbas cannot carcinog carcinogenesi carcinoma cardiac cardiovascular case case-control categor categori caucasian caus cause-specif causespecif caval cavalli-sforza caviti cdc cell censor census cerfolio certain cervic cervix chang characterist chemoprevent chen cheng chest chien chines chronic chun ci cigarett cis citi cl classifi close cmaj cncr27 cohen cohort coleman colon colorect colorectum combin come comment common communiti compar comparison conclus conduct confid confound connecticut consid consider consist constant consumpt content contin continu contrast contribut control corpus correct could count countri covari cover cox creat cultur cummin cuneo curcumin curri d dale data databas day dd de death dec decemb decreas delaimi demograph design despit detect determin detroit develop dh diabet diagnos diagnosi die diet dietari differ differenti diffus digest disappear discuss diseas disease-rel distant distribut divers divid diwan dl dm doi domin dos draw drawn ds du ductal due e e-mail earlier east econom educ effect either emphasis en end england enjoy enough epidemiol epidemiolog equal error errors-in-vari esophag esophagus especi estim estrogen ethnic eur european even event exact examin except excess exp expect experi explain exposur extens extent extranod fact factfind factfinder.census.gov factfinder.census.gov/servlet/dtgeosearchbylistservlet? factfinder.census.gov/servlet/safff factor factsheet farooq fashion favor feel femal ferlay file files/ethnic.pdf filipino find first fit five fleme follow food form forman found four francisco franco free function futur g gastric gen gender gender-specif gene general genet geograph given glioblastoma goggin grace grade grambsch great greater group guid gum h hazard health healthi heath hergert high higher himmelstein hispan histolog histor hodgkin home/files/edu/report_1968_2002.pdf hong household howev iarc identifi ii iii iii/iv immigr impact import improv incid includ inclus incom increas inde india indian indian/pakistani indians/pakistani indians/pakistanis indianspakistani indic inequ infer influenc inform ingredi innov institut int intak intern interpol interv interview introduct island iv j jain johnston jonnalagadda jose jr juli kagawa kagawa-sing kaiserman kaplan ke keyword kidney kidney/renal kingdom kk know known kong krewski ks l lagergren lang languag lankan larg larger largest larynx least length less leukemia li lifestyl like limit linear literatur littl live liver ll lm lobular local long long-term los low lower lump lung lymphocyt lymphoma lyon m made madra magnitud mail major make malay malaysia male malign malon mammogram mangtani mani manuscript margin maric martingal martingalebas matur may mayer mccormack mcmichael meat med media median medic meier metastasi method mill million minor misclassif miss mix mmwr model modest mohanti mondial month morb morimoto mortal most mouth mp multi multi-sit myeloid myeloma n na nair name nargundkar nation nationwid nativ natur nci ne necessari neoplasm nethersol never neversmok nhl nk nk-cell non non-differenti non-hispan non-hodgkin non-proport non-signific non-smal non-south nonhispan nonsignific nos notabl note novemb number nurs nutr obes object observ obtain occup oct oesophag offic often omit one onlin option oral order origin other outcom ovari ovarian overal overlap p p-valu pacif pakistan pakistani pancrea pancreat paper parikh parikh-patel parkin part particular patel patient pattern pelvi peopl per percentag perform period person person-year pharynx physic phyto phyto-estrogen pierr pl plot pm poor popul population-bas possibl pourat powder practic preced present press prev preval previous primarili problem profil prognos prognosi program proport prostat protect public publish purpos pyramid quadrat qualiti quantiti quartil quinn quit r race racial racial/ethnic rang rapid rate ratio receiv recent record rectal rectum reduc refer reflect region registri registrybas relat relev renal rep report report/ncr2ndreport.pdf research resembl resid residu respect respons restrict result review rf risk rj rock room rr rrs rv sa sampl san santo scatterplot school scienc scientif screen seattl second seem seer seerstat segment selbi self self-examin separ serv ses sevak seven sever sf4 sforza shatin sheet sheth show shown siemiatycki signific silcock silva similar sinc singapor singer singl sir site site-specif sitespecif six size sl slight small smoke smoker smoking-rel socioeconom soft solid somewhat south specif springer squamous sri ss sse stage standard standardis state statist status stavola stay stomach storm stratif strength strong stronger studi subcontin subject submenuid substanti summari sundelof surh surpris surveil survey surviv sweden system tabl tail tayyem tempor tend tendenc term test thank therneau thus thyroid time tissu tm togeth tom tongu topic tr trait treat treatment trend ts tumer tumor turmer two two-tail ty type u u.k u.s undoubt unit univers unstag urinari us use uteri v valu varghes variabl variat varieti various veget velikova verifi viii visual vol volum vs w wale way wealthiest well well-abov well-educ west [email protected] whelan wherea whether white whose william winter within wk wkli women wong woolhandl world wors worsen would wu www.cabinetoffice.gov.uk www.cabinetoffice.gov.uk/strategy/downloads/ www.crc.gov.my www.crc.gov.my/publications/documents/ www.hpb.gov.sg www.hpb.gov.sg/data/hpb. x ye year yj yorkshir yusuf yw á æ ó