Uncovering the Hidden Drivers Behind Rising Cancer Rates in Asian American Communities

Based on your preliminary data so far, are you already seeing distinct cancer risk patterns across different Asian American subgroups?

As we lead the Greater Bay Area Cancer Registry, we have an opportunity and a responsibility to monitor emerging patterns and trends of cancer across our diverse populations. For most Asian American groups, cancer has been for decades the leading cause of death. However we know that the category “Asian American” is actually exceedingly heterogeneous, comprising people with origins from 30 countries, hundreds of different languages and dialects, and varying immigration patterns. As we would expect, this translates into vastly different cancer patterns.

Examples of unique and dynamic patterns in cancer risk among Asian American ethnicities:

• Among San Francisco Bay Area Asian Americans, breast cancer risk is higher among immigrant relative to U.S.-born, signaling a potential shift in breast cancer risk.
• Lung cancer incidence rates are 1.5-2 times higher among most Asian American females who never smoked relative to non-Hispanic White (NHW) females who never smoked due, in part, to culturally-unique risk factors such as exposure to cooking oil fumes, smoke from coal, and lung infections.
• Korean Americans are five times more likely to develop gastric cancer than NHW as a result of higher H. pylori infection rates and unique dietary factors.
• Liver cancer rates among Southeast Asian Americans and cervical cancer rates among Vietnamese American women are among the highest in the world, in part due to the high prevalence of HBV and HPV infection, respectively.
• Thyroid cancer incidence and mortality rates are high among Filipino Americans, even accounting for more sensitive detection methods.
• Frequently, data on Asian Americans and Native Hawaiians and Pacific Islanders (NHPI) are aggregated, even though NHPIs have distinct sociodemographics, exposures, and cancer profiles.

Counter to the prevailing view that Asian Americans have high socioeconomic status and favorable health, certain groups have high rates of poverty, low healthcare access, and low rates of cancer screening. We believe that focusing efforts on identifying the underlying multilevel drivers of these emerging patterns will not only help us to design approaches to mitigate or reverse the increasing trends, but can also help us to identify emerging risk factors that will generally benefit all those at risk of these cancers.  

Have any early findings surprised you—particularly regarding cancers like lung cancer in non-smoking Asian American women or rising breast cancer rates in younger populations?

The magnitudes of the emerging patterns of increasing rates of breast cancer and high rates of lung cancer among females who have never smoked, are striking and present an urgent need to invest focused research to understand what is driving why we are seeing these patterns. Asian Americans are represented in <1% of research funded by the National Institutes of Health, and we are aiming to change that, through studies like FANS, CRANE, and ASPIRE.

We are particularly excited about our new study, the ASPIRE (Asian American Prospective Research) Cohort, as it is the first national cancer etiology cohort exclusively for Asian Americans. We see ASPIRE as more than a research study. It is really a national movement to ensure representation of every Asian American ethnic group in health research.   

To what extent do your early results suggest that social determinants—such as discrimination, access to care, or acculturation—are interacting with biological or genetic factors in driving cancer risk?

 The intersection of social drivers, such as neighborhood conditions, environmental factors, and access to culturally-and linguistically-appropriate resources, in addition to immigration and acculturation experiences, with biological and genomic factors are a central focus of our research. It’s still early for results, but we are finding so far that where you live can play as big of a role, sometimes an even larger role, in driving risk of cancer as one’s genetic predisposition. However, our studies have shown that the impacts of neighborhoods and environmental factors can vary across different groups and for different cancer outcomes.

For example, we have found that living in ethnic enclaves, neighborhoods with higher ethnic concentration but potentially also more culturally-concordant resources, may buffer against discrimination-mediated stressors, and is associated with improved cancer outcomes, likely through the process of co-ethnic social support and resource access. We believe that studying the roles of these social drivers, and the potential pathways by which they affect risk across the cancer continuum, can help us to design community-level interventions to improve cancer outcomes. These neighborhoods may also teach us about resiliency factors that can be scalable across otherwise disadvantaged or under-resourced communities.

If your findings continue to show major differences across Asian ethnic groups, how should screening guidelines or clinical risk assessments change in the near future?

Data from studies such as ours are important to establish whether different screening guidelines may be needed, such as lowering screening age for early onset cancers, expanding screening on the basis of risk factors, and/or more precise risk assessments that account for ethnic-specific factors. Our studies may also help developments in the application of AI in precision risk assessments.

What challenges have you faced in recruiting a truly representative cohort across diverse Asian American communities, and how might those challenges affect the interpretation of early results?

Indeed, an ambitious goal for us in the ASPIRE Cohort is to achieve a cohort that is representative of all Asian American ethnic groups, across all regions of the US. This relies on deploying a mix of different approaches, ranging from social media to traditional media to community outreach. We have presence in multiple Asian American communities across the US, where we and our academic partners have well established relationships with dozens of Asian American-serving community organizations in these communities; however, we need to establish presence and built relationships and trust with community organizations in other Asian ethnic groups and regions across the US, and we know that this relationship and trust building process takes time. In addition, although ASPIRE will be available in 8 Asian languages, we will nonetheless not be able to cover all languages and will not be able to enroll participants who cannot engage in one of the 8 languages.

We are finding that it is a particularly difficult time to conduct this kind of research given that many community organizations are resource-constrained, and people are more cautious about participating in federally-funded efforts, and in providing certain sensitive information. Furthermore, we have found that fraudulent activity in study participation motivated by study incentives has become pervasive. Throughout the project, we work very closely with our community advisory boards, who provide invaluable guidance in helping us to navigate these issues.

Given the historic underinvestment in health research for generally underrepresented communities/ Asian Americans, are there concerns about current/future funding, and/or any new potential opportunities?

Yes, we are deeply concerned about the underinvestment in health research for Asian American [and Native Hawaiian/Pacific Islander] populations. The U.S. spends more on health than any other county, yet we experience the worse health outcomes in comparison to other high-income countries. And sadly, underrepresented and marginalized communities, including distinct Asian American communities, experience a disproportionate burden of worse health outcomes and poor health. Looking to the future, we hope our nation is able to rebuild our infrastructure of supporting health research such that the health needs of all communities can be investigated, addressed, and wellness can be achieved.