Expert Insight Into: Cancer Incidence, Mortality, and Associated Risk Factors Among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese Ethnicities

Projects In Knowledge is committed to protecting the privacy and confidentiality of visitors to our Web site. While Projects In Knowledge does not require that you provide us with personally identifiable information in order to visit our Web site, please note that in order to participate in the continuing medical education activities that we provide, it will be necessary for you to register with us and provide this information.

About this Privacy Policy
www.projectsinknowledge.com is our Web site for physicians and allied health care professionals, although it is open to non-professionals as well. The purpose of projectsinknowledge.com is to provide continuing medical education for healthcare professionals, and is intended for use only by a licensed healthcare professional.

Projects In Knowledge is the name we use to refer to our entire company, even though our formal corporate name is Projects In Knowledge, Inc. When we refer to ourselves as "we" or "Projects In Knowledge," we mean our company, Projects In Knowledge, Inc., including any subsidiary that we control (for example, a subsidiary that we own). We may share information among our subsidiaries that we own or control, but it is always protected under the terms of this privacy policy.

This privacy policy applies only to the Projects In Knowledge Web site. You should read the privacy policy at each Web site that you visit after you leave our site. We are not responsible for how other Web sites treat your privacy, once you leave the Projects In Knowledge site.

Privacy Policy Changes
If we change our privacy policy, we will post those changes on this page. Users should check this policy to keep abreast of any changes.

Information We Collect
In this section of our privacy policy, we discuss the different types of information we may collect about you, and the ways in which we collect them.

Information We Collect from Unregistered Visitors
Visitors to our Web site can access the Web site's home page and browse the site without disclosing any personally identifiable information. We do track information provided to us by your browser, including the Web site you came from (known as the "referring URL"), the type of browser you use, the time and date of access, and other information that does not personally identify you.

Information We Collect When You Register
Customers registering on our Web site for continuing medical education activities we provide are asked to provide us with identifying information, such as name, contact information, and other identifying information. On our registration screens, we clearly label which information is required for registration, and which information is optional and may be given at your discretion.

On our registration screens you will also find a “Burning Question” field. Submission of a “Burning Question” is completely voluntary. By submitting a “Burning Question,” you grant Projects In Knowledge the right to share it with faculty to consider as they prepare their continuing medical education presentations.

Listserves
When you are using a listserve—or member-only discussion board— on our Web site, you are posting a message and your user name, which is available for all registered members to see. You should not post any information to our listserves you want to keep private. It is a condition of our Web site that when participating in a listserve, you do not:

Restrict or inhibit any other user from using the listserve

Post or transmit any unlawful, threatening, abusive, libelous, defamatory, obscene, vulgar, pornographic, profane or indecent information of any kind, including, without limitation, any transmission constituting or encouraging conduct that would constitute a criminal offense, give rise to civil liability or otherwise violate any local, state, national or foreign law

Post or transmit any information, software or other material which violates or infringes upon the rights of others, including material which constitutes an invasion of privacy or infringement of publicity rights or which is protected by copyright, trademark or other proprietary right, or derivative works thereof, without first obtaining permission from the owner or right holder

Post or transmit any information, software or other material which contains a virus or other harmful component

Post, or transmit, or in any way exploit any information, software or other material for commercial purposes which contains advertising, promotions or marketing

By sending a message through the listserve, you grant Projects In Knowledge the non-exclusive right and license to display, copy, publish, distribute, transmit, print, and use such information. Projects In Knowledge reserves the right to terminate your access to, and use of, the listserve if you do not abide by these conditions.

Use of Cookies
Cookies are a technology used by the Projects In Knowledge Web site to identify a user as the user moves through the Web site. Your browser allows us to place some information on your computer's hard drive that identifies the computer you are using. We use cookies to track your usage throughout our Web site.

Your Web browser can be set to allow you to control whether you will accept cookies, reject cookies, or to notify you each time a cookie is sent to you. If your browser is set to reject cookies, Web sites that are cookie-enabled will not recognize you when you return to the Web site, and some Web site functionality may be lost. The Help section of your browser will tell you how to prevent your browser from accepting cookies.

Although cookies do not normally contain personally identifiable information, if you are a registered user we may associate your registration information with cookies our Web site places on your computer's hard drive. Associating a cookie with your registration data allows us to offer increased personalization and functionality. For example, you can elect to have our Web site "remember" you and bypass the registration process each time you register for one of our educational activities. Without cookies, this functionality would not be possible. Projects In Knowledge does not currently employ cookies for this use, but is considering it to make our registration processes more efficient for you.

Children's Privacy
Projects In Knowledge's Web site is designed and intended for use by adults, and is not intended for, nor designed to be used by children under the age of 18, or any other unlicensed, untrained individuals. We do not collect personally identifiable information from any person we know is a child under the age of 18.

Uses We Make of Information
In this section of our privacy policy, we identify the ways we may use information about you that we have collected.

Aggregate Data
We create aggregate data about visitors to our Web site for activity development and improvement. We also use it for market analysis. We may provide information from our Web site in aggregate form, with identifying information removed, to third parties. For example, we may tell a third party what percentage of our registered users reside in a particular geographical area. When aggregated information is provided, we pool it from many individual records and strip it of any data that could be used to identify an individual before it is used. Any third party that receives aggregated data must agree not to attempt to re-identify the people it belongs to. Projects In Knowledge does not sell any user data to any third party for commercial purposes.

Third Parties
In addition to aggregate information (discussed previously), we may share some kinds of information with third parties as described below.

Business Transfers: If we transfer a business unit (such as a subsidiary) or an asset (such as a Web site) to another company, we will require them to honor the applicable terms of this privacy policy.

Protection of Information
In this section of our privacy policy, we discuss the security measures we take to protect information that we have collected about you.

General Policies
We have implemented technology and security policies, rules and other measures to protect the personal data that we have under our control from unauthorized access, improper use, alteration, unlawful or accidental destruction, and accidental loss. We also protect your information by requiring that all our employees and others who have access to or are associated with the processing of your data respect your confidentiality. In addition, we have appropriate security measures in place in our physical facilities to protect against the loss or misuse of information at our site that we have collected from you.

Projects In Knowledge Employees
Projects In Knowledge employees are required to keep customer information private, as a condition of their employment with the company. Only selected, authorized Projects In Knowledge employees are permitted to access your registration information.
Employees are required to sign a confidentiality agreement. All employees and contractors must abide by our privacy policy, and those who violate that policy are subject to disciplinary action, up to and including termination of their employment and legal action.

Privacy Questions or Concerns about Our Web Site
For privacy questions or concerns about the Projects In Knowledge Web site, please contact privacy@projectsinknowledge.com.

Revision date: This policy was last updated on September 30, 2003.

The Asian-American and Pacific Islander population, including Vietnamese, Korean, Chinese, Filipino, and Japanese ethnicities, is among the most rapidly expanding heterogeneous groups in the United States. Perhaps not surprisingly, epidemiologic data show some striking differences in disease and mortality rates among these ethnicities compared with non–Asian-American populations. For example, the annual incidence of cancer-related mortalities among Asian Americans and Pacific Islanders is higher than that for heart disease, the only ethnic groups in the United States for which this is the case.¹ Further, there is a higher incidence of cancers among Asian Americans and Pacific Islanders not typically seen in the Westernized countries.

Expert Commentary

Liver cancer incidence in California is highest in Vietnamese men (54.3/100,000, eight times higher than non-Hispanic whites), followed by Koreans and Chinese.
HBV is the major cause of liver cancer in most Asians.
Lower screening rates were seen in recent immigrants with poorer English proficiency, socioeconomic status, and education.

A recent paper by McCracken et al evaluated national data sets associated with the leading types of cancers in the Asian and Pacific Islander populations, specifically those who live in California, and found liver, lung, and cervical carcinomas to be among the leading types.² The researchers found both the highest incidence and mortality rates of all three cancers among Vietnamese Americans living in California.² Potential reasons for the high incidence and mortality rates in these populations differ and include recent immigration from geographic regions associated with higher rates of infectious diseases not commonly seen in the West. We focus here on the incidence and mortality of liver cancer, as it relates to the Asian-American and Pacific Islander populations living in the United States, and California specifically.

Hepatocellular carcinoma (HCC) is very high among Asians in general, and among the Vietnamese, Koreans, and Chinese in particular.³ The increased prevalence of liver cancer is believed to be associated with the higher rate of chronic hepatitis B virus (HBV) infection seen in Vietnam, Korea, and China. HBV infection is more prevalent in the developing world, Asia, and Sub-Saharan Africa, and is the main cause of liver cancer in those areas.⁴ Of note, 55% of the worldwide incidence of liver cancer occurs in China.⁴

While no national database currently exists to track the incidence, mortality, and risk factors for cancers among Asian Americans and Pacific Islanders ethnicities in the United States, data on incidence and mortality are available from both the Surveillance, Epidemiology, and End Results (SEER) regions, including California and Hawaii, and the California Cancer Registry (CCR). Data on risk factors and screening behaviors are available from the California Health Interview Survey (CHIS). Of note, approximately 3.7 million Asian Americans, or 12% of the total Asian-American population, resides in California.

In looking at the data from SEER (1988–1992) and CCR (2000–2002), McCracken et al found the incidence of liver cancer among Vietnamese men residing in California to be 54.3 per 100,000 with a mortality rate of 35.5 per 100,000. (See Table).² The incidence and mortality rates among Vietnamese women were 15.8 and 10.4 per 100,000, respectively, second only to the incidence and mortality rates seen in Korean women, which were 15.9 and 11.5 per 100,000, respectively. Korean men who reside in California had the second highest incidence and mortality rates of liver cancer: 33.7 and 26.6 per 100,000, respectively.²

The incidence of liver cancer and related mortality among Chinese men living in California were 23.3 and 19.9 per 100,000, respectively. Among Chinese women, the incidence and mortality rates were 7.6 and 7.8 per 100,000, respectively.² (See Table).

Table
Age-Adjusted Liver Cancer Rates (per 100,000) by Asian American Ethnic Group, California, 2000-2002, California Cancer Registry²

Incidence	Chinese	Filipino	Vietnamese	Korean	Japanese	Total	Non-Hispanic White
Male	23.3	16.8	54.3*	33.7*	9.3	23.8	6.8
Female	7.6	5.4	15.8	15.9	8.1	8.8	2.5

Mortality	Chinese	Filipino	Vietnamese	Korean	Japanese	Total	Non-Hispanic White
Male	19.9	12.0	35.5*	26.6*	8.3	17.9	6.0
Female	7.8	4.2	10.4	11.5	7.8	7.4	2.7

* The two highest rates for each gender-specific cancer site among the Asian ethnic groups.

While screening with serum AFP and liver ultrasound every 6 months can detect liver cancer at an earlier and more treatable stage, screening rates for liver cancer are low among some Asian populations⁵, and particularly among those with recent immigration histories. Limited language abilities, specifically English proficiency, lower socioeconomic status and educational levels, as well as cultural factors all represent potential barriers to healthcare and low screening rates.² For example, sociodemographic data from the US Census Bureau from 2000, broken down by ethnic group, show that Vietnamese living in California have the lowest levels of education and income of the Asian ethnicities living in that state, and the second lowest rates of health insurance: as the earlier data showed, Vietnamese-American males have the highest incidence of HCC and associated mortality among Asian-American ethnicities.²

Of all the factors that contribute to low screening rates, insufficient English likely represents a more broadly applicable barrier to healthcare and may be the most easily overcome. Of note, the Asian American Network for Cancer Awareness Research and Training, which is funded by the National Cancer Institute and the American Cancer Society, have developed a searchable Web portal for cancer materials for the general public available in 12 Asian languages.

HBV vaccination, hepatitis B-immune globulin administration, and antiviral treatment should be used to reduce the spread of HBV, particularly among people at high risk, such as those with cirrhosis or neonates born to HBV-infected mothers.⁶

Given that the Asian-American and Pacific Islander populations are among the fastest growing ethnic populations in the United States, and given that the incidence of HCC in these populations results in part from HBV infection more commonly seen in their countries of origin, improved screening and surveillance should be undertaken to reduce the incidence of HBV and subsequently the associated incidence and mortality rates of HCC.

References

National Center for Health Statistics. Health United States, 2006 with Chartbook on Trends in the Health of Americans. Hyattsville, MD: National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/hus.htm. Accessed September 14, 2007.
McCracken M, Olsen M, Chen MS, et al. Cancer incidence, mortality and associated risk factors among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese ethnicities. CA: A Cancer J Clin. 2007;57:190-205.
American Cancer Society. Cancer Facts & Figures 2005. Atlanta, GA: American Cancer Society 2005. Available at: http://www.cancer.org/docroot/STT/content/STT_1x_Cancer_Facts__Figures_2005.asp. Accessed September 14, 2007.
Stewart BW, Kleihues P. World Cancer Report. Lyon, France: IARC Press; 2003.
Zhang BH, Yang BH, Tang ZY. J Cancer Res Clin Oncol. 2004;130:417-22.
Gish RG. Improving outcomes for patients with chronic hepatitis B. Curr Gastroenterol Rep. 2007;9:14-22.

Privacy Policy

Expert Insight Into:
Cancer Incidence, Mortality, and Associated Risk Factors Among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese Ethnicities

By Claire Sowerbutt
Expert Commentary by Mindie Nguyen, MD, MAS

Available for CME/CE:

Physicians

Nurses

Estimated time for completion of this activity:

Target Audience

Activity Goal

Learning Objective (s)

CME Information: Physicians

Statement of Accreditation

Credit Designation

CE Information: Nurses

CME/CE Instructions

Available for CME/CE:

Physicians

Nurses

Estimated time for completion of this activity:

Target Audience

Activity Goal

Learning Objective (s)

CME Information: Physicians

Statement of Accreditation

Credit Designation

CE Information: Nurses

CME/CE Instructions

Privacy Policy

Expert Insight Into: Cancer Incidence, Mortality, and Associated Risk Factors Among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese Ethnicities

By Claire Sowerbutt Expert Commentary by Mindie Nguyen, MD, MAS

Available for CME/CE:

Physicians

Nurses

Estimated time for completion of this activity:

Target Audience

Activity Goal

Learning Objective (s)

CME Information: Physicians

Statement of Accreditation

Credit Designation

CE Information: Nurses

CME/CE Instructions

Available for CME/CE:

Physicians

Nurses

Estimated time for completion of this activity:

Target Audience

Activity Goal

Learning Objective (s)

CME Information: Physicians

Statement of Accreditation

Credit Designation

CE Information: Nurses

CME/CE Instructions

Expert Insight Into:
Cancer Incidence, Mortality, and Associated Risk Factors Among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese Ethnicities

By Claire Sowerbutt
Expert Commentary by Mindie Nguyen, MD, MAS