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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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