Disparities in Survival and Comorbidity Burden Between Asian and Native Hawaiian and Other Pacific Islander Patients With Cancer

Abstract

ImportanceImproper aggregation of Native Hawaiian and other Pacific Islander individuals with Asian individuals can mask Native Hawaiian and other Pacific Islander patient outcomes. A comprehensive assessment of cancer disparities comparing Asian with Native Hawaiian and other Pacific Islander populations is lacking.ObjectiveTo compare comorbidity burden and survival among East Asian, Native Hawaiian and other Pacific Islander, South Asian, and Southeast Asian individuals with non-Hispanic White individuals with cancer.Design, Setting, and ParticipantsThis retrospective cohort study used a national hospital-based oncology database enriched with Native Hawaiian and other Pacific Islander and Asian populations. Asian, Native Hawaiian and other Pacific Islander, and White individuals diagnosed with the most common cancers who received treatment from January 1, 2004, to December 31, 2017, were included. Patients younger than 18 years, without pathologic confirmation of cancer, or with metastatic disease were excluded. Data were analyzed from January to May 2022.Main Outcomes and MeasuresThe primary end points were comorbidity burden by Charlson-Deyo Comorbidity Index and overall survival (OS).ResultsIn total, 5 955 550 patients were assessed, including 60 047 East Asian, 11 512 Native Hawaiian and other Pacific Islander, 25 966 South Asian, 42 815 Southeast Asian, and 5 815 210 White patients. The median (IQR) age was 65 (56-74) years, median (IQR) follow-up was 58 (30-96) months, and 3 384 960 (57%) were women. Patients were predominantly from metropolitan areas (4 834 457 patients [84%]) and the Southern United States (1 987 506 patients [34%]), with above median education (3 576 460 patients [65%]), and without comorbidities (4 603 386 patients [77%]). Cancers included breast (1 895 351 patients [32%]), prostate (948 583 patients [16%]), kidney or bladder (689 187 patients [12%]), lung (665 622 patients [11%]), colorectal (659 165 patients [11%]), melanoma (459 904 patients [8%]), endometrial (307 401 patients [5%]), lymphoma (245 003 patients [4%]), and oral cavity (85 334 patients [1%]) malignant neoplasms. Native Hawaiian and other Pacific Islander patients had the highest comorbidity burden (adjusted odds ratio [aOR], 1.70; 95% CI, 1.47-1.94) compared with Asian and White groups. Asian patients had superior OS compared with White patients for most cancers; only Southeast Asian patients with lymphoma had inferior survival (adjusted hazard ratio [aHR], 1.26; 95% CI, 1.16-1.37). In contrast, Native Hawaiian and other Pacific Islander patients demonstrated inferior OS compared with Asian and White patients for oral cavity cancer (aHR, 1.56; 95% CI, 1.14-2.13), lymphoma (aHR, 1.35; 95% CI, 1.11-1.63), endometrial cancer (aHR, 1.30; 95% CI, 1.12-1.50), prostate cancer (aHR, 1.29; 95% CI, 1.14-1.46), and breast cancer (aHR, 1.09; 95% CI, 1.00-1.18). No cancers among Native Hawaiian and other Pacific Islander patients had superior OS compared with White patients.Conclusions and RelevanceIn this cohort study, compared with White patients with the most common cancers, Asian patients had superior survival outcomes while Native Hawaiian and other Pacific Islander patients had inferior survival outcomes. Native Hawaiian and other Pacific Islander patients had significantly greater comorbidity burden compared with Asian and White patients, but this alone did not explain the poor survival outcomes. These results support the disaggregation of these groups in cancer studies.

Racial and Ethnic Disparity in Preoperative Chemosensitivity and Survival in Patients With Early-Stage Breast Cancer

“…Asian and Hispanic patients were found to have better survival outcomes in our study, which agrees with the findings from other studies . Many Asian individuals have lower body mass index and fewer comorbidities, which are known to be protective mediators in breast cancer mortality . Asian patients are reported to have higher ERBB2 + disease, which has a good response to NACT, and may be another reason for their improved survival .…”

“…[15][16][17] Many Asian individuals have lower body mass index and fewer comorbidities, which are known to be protective mediators in breast cancer mortality. 17,18 Asian patients are reported to have higher ERBB2 + disease, which has a good response to NACT, and may be another reason for their improved survival. 15 Pan et al 19 found that Asian patients with breast cancer tumors have higher immune scores and higher levels of CD8 + T cells, macrophages, and cytotoxic natural killer cells, which suggest improved response to immunotherapy and better survival outcomes.…”

Diversity in Cancer Care

“…For example, minoritized populations have difficulty participating in trials given the mismatch in trial eligibility and these populations' disease stages, comorbidity burden, and other clinical characteristics 18,19 . This is concerning for Indigenous populations, such as the NHPI population, who are known to have greater burden of comorbidities and thus may be disproportionately excluded from clinical trial opportunities 20 . In another prospective study of 171 patients considered for participation in a clinical trial, only half had a potential trial opportunity available, given their cancer diagnosis and stage of disease 21 .…”

Advancing Therapies for Asian Americans, Native Hawaiians, and Other Pacific Islanders With Cancer: OCE's Project ASIATICA

“…2 However, NHPI patients with cancer continue to be underrepresented in oncology clinical trials and face even more significant health care disparities than AA patients with cancer, including worse outcomes and survival rates. 7 Although AAs are the fastest growing population in the United States, over the past three census data, funding for research remains low at only 0.17% of the total NIH-funded research from 1992 to 2018. 3,8,9 While funding for the overall AA & NHPI population is low, the difference is even more stark when the NHPI population is examined separately from AA populations.…”

“…2 However, NHPI patients with cancer continue to be under-represented in oncology clinical trials and face even more significant health care disparities than AA patients with cancer, including worse outcomes and survival rates. 7…”