cancer databases: israel de alba
TRANSCRIPT
Using CHIS data to explore Cancer screening disparities in California
Israel De Alba, MD MPHCenter for Health Policy ResearchDepartment of MedicineUniversity of California, Irvine
OverviewUsing 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
BackgroundCervical 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
BackgroundCervical 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
BackgroundStudy 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
Methods
Inclusion criteria:1. Women age ≥182. No hysterectomy
Outcomes1. Receipt of recent Pap smear
(in past 3 years)
2. Ever having a Pap smear
MethodsStatistical analysis
1. Descriptive statistics2. Bivariable analysis3. Logistic regression4. Generation of prevalence rate
ratios
MethodsLogistic 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
Methods
Asian Sub-groupsJapaneseFilipinoKoreanChineseVietnameseSouth Asians • (Bangladeshi, Indian, Pakistani, Sri Lankan,
and more than one of these nationalities)
MethodsAdjusting variables in logistic regressionAge
18-30, 31-40, 41-50 and ≥51Educational attainment
< high school, high school, > high schoolAnnual household income
< 200% FPL or ≥ 200% FPLHealth insurance
any coverage or no insuranceSelf-reported health status
excellent, very good or good vs. fair or poorAbility to speak English (only among ethnic sub-
groups)very well, well, not well and not all
Results: all womenDemographics (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%
Results: all womenPap 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
Results: Hispanic subgroup analysisPap 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
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
SummaryIn 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
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
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
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
Limitations
Self-report of receipt and timing of Pap smearLow response rate for 2001 CHIS (63.7%)
Non-response bias
Generalizability
Specific aim
To evaluate the relationship between U.S. citizenship status and receipt of Pap smears and mammograms among immigrant women in California.
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
OutcomesCervical 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 years4. Mammogram ever
Statistical analysisMultivariable logistic regression model for each outcomeAdjusting for:
AgeRace/ethnicity Educational attainmentAnnual household incomeHaving health insuranceYears in the U.S.Health statusEnglish language proficiency
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
ConclusionsNot 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.
Using CHIS data to explore cancer screening racial/ethnic disparities: overall impressions
Positive aspectsData easily availableWell designed, standardized questionnairesExcellent “customer service”High proportion of minority populations