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Geographic Disparities in Cancer in Hawaii

A Virtual ConferenceOncology Nursing Society Hawaii (Oahu) Chapter

October 16-17, 2020

Brenda Y. Hernandez, MPH, PhD

Learning Objectives

• To describe geographic disparities in cancer across the state of Hawaii and compared to the U.S. overall

• To describe other disparities in cancer within Hawaii’s population

~ 7,000 newly diagnosed cases annually

~ 2,300 deaths annually

• Average age of diagnoses: 66 years (males); 64 years (females)

• 55 pediatric (19 years and younger) cases annually

~ 62,000 cancer survivors

Snapshot of Cancer In Hawaii

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Cause of Death %

Diseases of the heart 23%

Cancer 22%

Cerebrovascular disease 6%

Influenza/pneumonia 5%

Alzheimer's disease 4%

Chronic lower respiratory diseases 3%

Diabetes mellitus 3%

Nephritis and nephrosis 2%

Intentional self-harm (suicide) 2%

Motor vehicle accidents 1%

Chronic liver disease and cirrhosis 1%

Hypertension 1%

Other 27%

Total 100%

Top Causes of Death, Hawaii, 2016

Source: Hawaii State Department of Health

Average Annual Number of Cancer Cases and Death, by County, Hawaii, 2012-2016

Honolulu CountyCases 4,891 (70%)Deaths 1,593 (68%)

Hawai‘i CountyCases 977, 14%Deaths 366, 16%

Maui County* (Maui, Moloka‘i, Lana‘i)

Cases 797, 11%Deaths 266, 11%Kaua‘i County

Cases 343, 5%Deaths 143, 5%

Insurance status of cancer patients, Hawaii, 2013-2017

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Top Cancers in Hawaii, Newly Diagnosed Cases, 2012-2016

MALES FEMALES

Top Causes of Cancer Deaths in Hawaii, 2012-2016

MALES FEMALES

Relative 5-Year Survival, Males, Hawaii, 2009-2016

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

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Relative 5-Year Survival, Females, Hawaii, 2009-2016

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Hawaii: 416.5 vs. United States: 448.7

Source: Adapted from the NCI and the CDC

Cancer Incidence (New Cases per 100,000), All Cancer Sites,

Both Sexes, United States, 2013-2017

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Cancers of Higher Incidence in Hawaii Compared to the U.S., 2012-2016

0 20 40 60 80 100 120 140 160

Breast

Liver & Intrahepatic Bile Duct

Oral Cavity & Pharynx

Stomach

Uterus/Endometrium

Colon & Rectum

Liver & Intrahepatic Bile Duct

Stomach

Fem

ale

Ma

le

Age-adjusted rate per 100,000

U.S. Incidence Rate Hawaii Incidence Rate

Cancers Mortality (Deaths per 100,000), All Cancer Sites, Both Sexes,

United States, 2014-2018

Source: Adapted from the NCI and the U.S. National Vital Statistics System

Hawaii: 130.1 vs. United States: 155.5

Cancers of Higher Mortality in Hawaii Compared to the U.S., 2012-2016

0 2 4 6 8 10 12 14

Liver & Intrahepatic Bile Duct

Stomach

Liver & Intrahepatic Bile Duct

Stomach

Fem

ale

Ma

le

Age-adjusted rate per 100,000

U.S. Mortality Rate Hawaii Mortality Rate

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Average Annual Percent Change in Cancer Incidence Rates, Males, Hawai‘i, 2007-2016

Average Annual Percent Change in Cancer Incidence Rates, Females, Hawai‘i, 2007-2016

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Average Annual Percent Change in Cancer Mortality Rates, Males, Hawai‘i, 2007-2016

Average Annual Percent Change in Cancer Mortality Rates, Females, Hawai‘i, 2007-2016

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Breast Cancer Incidence and Mortality, 1987-2016

Female Breast Cancer Incidence (New Cases per 100,000),

United States, 2013-2017

Source: Adapted from the NCI and CDC

Hawaii: 138.9 United States: 125.9

Source: Adapted from the CDC

Women aged 50-74 who have had a mammogram within the past two years,

U.S., 2018

Hawaii: 87% United States: 78.3%

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Breast Cancer Incidence and Mortality, by Race/Ethnicity, Hawai‘i, 2012-2016

Breast Cancer Stage Distribution, Hawai‘i, 2012-2016

Lung & Bronchus Cancer Incidence and Mortality, 1987-2016

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Lung & Bronchus Cancer Incidence (New Cases per 100,000),

Both Sexes, United States, 2013-2017

Hawaii: 45.7 vs. United States: 58.3

Source: Adapted from the NCI and CDC

Current Smoking Among Adults Ages 18+ Years , U.S., 2018

Source: Adapted from the CDC

Hawaii: 13.4% United States: 16.1%

Lung & Bronchus Cancer Incidence and Mortality, Hawai‘i, 2012-2016

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Lung & Bronchus Cancer Stage Distribution, Hawai‘i, 2012-2016

Average Annual Number of Cancer Cases and Deaths, by County, Hawai‘i, 2012-2016

Overall Cancer Incidence and Mortality by County, Hawai‘i, 2012-2016

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Melanoma of the Skin Incidence and Mortality by County, Hawai‘i, 2012-2016

Melanoma of the Skin Incidence and Mortality, By Race/Ethnicity, Hawai‘i, 2012-2016

Insurance status of cancer patients, by County, Hawaii, 2013-2017

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Proportion of Neighbor Island Patients Receiving Cancer Treatment (All or In Part) in Oahu Medical Facilities, Hawaii, 2013-2017

43% 45%

34%

45%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

All (Hawaii, Maui,Kauai)

Hawaii County Kauai County Maui County

Neighbor Island Patients Treated on Oahu, by Treatment Type, Hawaii, 2013-2017

Surgery only , 64.3%

Chemotherapy only, 6.1%

Radation therapy only, 4.3%

Hormonal therapy only, 2.3%

Biological Response Modifiers with or without other treatments, 2.4%

Other combination treatment, 20.5%

Mean Time (Days) to Cancer Treatment Initiation, by Sex, Hawaii, 2013-2017

39.0

30.4

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

Tim

e to

tre

atm

en

t (d

ays)

Male Female

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Mean Time (days) to Cancer Treatment Initiation, by Sex and County, Hawaii, 2013-2017

39.0 39.7 37.333.7

45.9

30.4 30.1

33.6

28.6

31.0

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Statewide Honolulu County Hawaii County Maui County Kauai County

Tim

e to

tre

atm

en

t (d

ay

s)

Male Female

Mean Time (Days) to Cancer Treatment Initiation, by Sex and Race/Ethnicity, Hawaii, 2013-2017

42.5

42.0

38.341.2

36.1

41.6

28.1

33.0 33.9

29.627.5

32.5

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Chinese Filipino Hawaiian Japanese White Other

Tim

e to

tre

atm

en

t (d

ay

s)

Male Female

Mean Time (Days) to Cancer Treatment, by Insurance Status, Hawaii, 2013-2017

26.3 31.632.4

35.735.7

43.1

43.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Uninsured Private Insurance Other Medicare Medicaid Unknown Military

Tim

e to

tre

atm

en

t (D

ays)

.

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Proportion of Patients Refusing of Recommended First Course Cancer Therapy, Hawaii, 2013-2017

10% of cancer patients refused recommended first course cancer treatment

Pe

rce

nt

Re

fusa

l

Proportion of Patients Refusing of Recommended First Course Cancer Therapy, by County Hawaii, 2013-2017

8.5%

7.8%8.1%

7.3%

12.1%

11.4% 11.5%11.1%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

Honolulu County Hawaii County Maui County Kauai County

Perc

en

t R

efu

sed

Male Female

Proportion of Patients Refusing of Recommended First Course Cancer Therapy, by Race/Ethnicity, Hawaii, 2013-2017

9.5%

7.5%

9.7%

8.3%

7.6%

10.2%

11.9%

10.1%

11.8%12.2%

12.7% 12.9%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

Chinese Filipino Hawaiian Japanese White Other

Perc

en

t R

efu

sal

Male Female

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Proportion of Cancer Patients Refusing Recommended First Course Therapy, by Treatment Type, Hawaii, 2013-2017

4.1%

1.2%

14.1%

4.8%

6.2%6.8%

2.6%1.6%

18.2%

7.3%6.6%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

Pe

rce

nt

Re

fus

al

.

Male Female

Proportion of Cancer Patients Refusing Recommended First Course Chemotherapy, by County, Hawaii, 2013-2017

14.3%

12.5%

15.6%

12.5%

18.4%

16.0%

20.7%

16.2%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Honolulu County Hawaii County Maui County Kauai County

Perc

en

t R

efu

sal

Male Female

Proportion of Cancer Patients Refusing Recommended First Course Chemotherapy, by Race/Ethnicity, Hawaii, 2013-2017

14.1%15.1%

12.5%

13.9%

15.3%

13.5%

15.5%

18.2%

16.9%

14.5%

17.8%

19.6%20.5%

17.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

All Races Chinese Filipino Hawaiian Japanese White Other

Perc

en

t R

efu

sal

Male Female

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Proportional of Breast Cancer Patients Refusing of Recommended First Course Cancer Treatment, Hawaii, 2013-2017

Perc

en

t R

efu

sal

Cited Reasons for Treatment Refusal, Breast Cancer Patients, Hawaii, 2013-2017

• Age

• Potential adverse events and side effects, e.g., risk of thromboembolic events, cardiac events, cerebrovascular accident, breast erythema

• Alternative therapy, e.g., naturopathy, organic juices, natural remedies, natural healing

• Existing comorbidities, poor health status

• Concerns of being out of work

• Religious/spiritual beliefs

• Desire to have children, nurse

• Perceived low possible benefit

• Effect on quality of life

• Homelessness

0.0 50.0 100.0 150.0 200.0 250.0 300.0 350.0 400.0

Postmenopausal Female Breast

Colon & Rectum

Uterus/Endometrium

Thyroid

Kidney

Pancreas

Ovary

Liver

Multiple Myeloma

Gastric Cardia

Esophageal Adenocarcinoma

Gallbladder

Meningioma

Age-adjusted rate per 100,000

Hawaii

U.S. (SEER 18)

Source: Adapted from the NCI and CDC

Obesity-Associated Cancer Incidence, Selected Sites,

Hawaii and U.S. (SEER), 2013-2017

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Prevalence of Obesity (Body Mass Index 30+) Among Adults Ages

20 +Years , U.S., 2018

Hawaii: 25.2% United States: 31.6%

Source: Adapted from the CDC

Uterus/Endometrium Cancer Incidence and Mortality, By Race/Ethnicity, Hawai‘i, 2012-2016

Liver & Intrahepatic Bile Duct Incidence and Mortality, By Race/Ethnicity, Hawai‘i, 2012-2016

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Liver & Intrahepatic Bile Duct Cancer Incidence

(New Cases per 100,000), United States, 2013-2017

Hawaii: 11.2 vs. United States: 8.4

Source: Adapted from the NCI and the CDC

Liver cancer risk factors

Hepatitis B

Hepatitis C

Alcohol

Other: Smoking, Genetic

Susceptibility, Aflatoxin

Obesity, Diabetes/

Insulin Resistance

Oral Cavity & Pharynx Incidence and Mortality, By Race/Ethnicity, Hawai‘i, 2012-2016

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Incidence of HPV-associated cancers by cancer Hawaii, 2012-2016

0 2 4 6 8 10 12 14 16 18 20

Oral Cavity & Pharynx - Males

Cervix

Oral Cavity & Pharynx - Females

Vulva

Anus- Females

Anus- Males

Vagina

Penis

Age-adjusted rate per 100,000

Increased Incidence of HPV-Positive Oropharyngeal Cancers

• HPV-positive tumor: 225% increase

• HPV-negative tumors: 50% decline

• Overall oropharynx: 28% increase

Chaturvedi et al, J Clin Oncol 2011

Top Cancers in Other Racial/Ethnic Groups, Males and Females Combined, Hawai‘i, 2012-2016

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US Affiliated Pacific Island Residents Undergoing Cancer Treatment in Hawaii, 2013-2017 (n=764)

American Samoa21%

Federated States of Micronesia

8%

Guam46%

Marshall Islands6%

Northern Mariana Islands

18%

Other1%

Mahalo!

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