PALO ALTO, CA – While federal guidelines have called for separating data for Native Hawaiian and other Pacific Islander individuals from data for Asian individuals, the cohorts often are aggregated or excluded completely in medical research, according to a new study.
The report in JAMA Network Open pointed out that Native Hawaiians and other Pacific Islanders share ancestry from nearly 30 island nations across Melanesia, Micronesia, and Polynesia; they also experience dissimilar health disparities, including higher rates of diabetes, obesity, asthma, and cardiovascular diseases, compared with Asians.1
“Moreover, the Asian population is not a monolithic group, and few studies have investigated the differences in clinical outcomes among East, South, and Southeast Asian patients,” explained researchers from Stanford University and the Palo Alto, CA, VA Hospital. This paucity of medical research masks existing disparities, which can influence public policy and funding allocation.2
The situation can be especially confusing with cancer, which is the leading cause of death for the Asian, Native Hawaiian, and other Pacific Islander populations in the United States. “However, most studies show that the aggregate group has superior cancer outcomes compared with non-Hispanic white (hereafter, White) individuals,” according to the article. “Reports enriched with Native Hawaiian and other Pacific Islander populations suggest inferior survival outcomes among Native Hawaiian and other Pacific Islander patients with cancer. To our knowledge, there is no comprehensive report on disaggregated Native Hawaiian and other Pacific Islander cancer disparities on a national scale. Thus, the objective of this study was to elucidate the heterogeneity in comorbidity burden and overall survival (OS) among a large cohort of Asian and Native Hawaiian and other Pacific Islander patients with cancer.”
The concern is that Improper aggregation of Native Hawaiian and other Pacific Islander individuals with Asians “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,” the study went on to state.
The authors sought to 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.
The 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 and who received treatment from Jan. 1, 2004, to Dec. 31, 2017, were included. Data analysis occurred from January to May 2022, with primary endpoints defined as comorbidity burden by Charlson-Deyo Comorbidity Index and overall survival (OS).
Of the nearly 6 million patients assessed, 60,047 were East Asian, 11,512 Native Hawaiian and other Pacific Islander, 25,966 South Asian, 42,815 Southeast Asian, and 5.8 million white patients. The median (IQR) age of participants, 57% women, was 65, and follow-up was a median of 58 months. Most, 84%, of the patients were from metropolitan areas, and 34% were from the Southern United States, The majority, 65%, had above median education and fewer than a fourth had comorbidities.
Participants were compared to white patients after being divided into the following groups:
- East Asian (Chinese, Japanese, and Korean),
- Native Hawaiian and other Pacific Islander (Native Hawaiian, Micronesian, Chamorro, Guamanian, Polynesian, Tahitian, Sāmoan, Tongan, Melanesian, Fiji Islander, New Guinean, and other Pacific Islander),
- South Asian (Indian and Pakistani), and
- Southeast Asian (Cambodian, Filipino, Hmong, Laotian, Kampuchean, Thai, and Vietnamese).
The focus was on colorectal cancer, which affected 11% of patients, as well as breast cancer, 32%; prostate cancer 16%; kidney or bladder cancer 12%, lung cancer 11%, endometrial cancer 5%; lymphoma 4%, and oral cavity cancer 1%.
Results indicated that 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. In fact, Asian patients had superior OS compared with white patients for most cancers, with only Southeast Asian patients with lymphoma having inferior survival (adjusted hazard ratio [aHR], 1.26; 95% CI, 1.16-1.37).
On the other hand, 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.
“In 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,” the authors concluded. “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.”
Researchers added, “The high comorbidity burden among Native Hawaiian and other Pacific Islander patients may impact critical treatment decisions, such as surgical candidacy or consideration for clinical trial enrollment. This may in part translate to inferior cancer outcomes. However, the association of inferior OS observed among Native Hawaiian and other Pacific Islander patients persisted even after controlling for comorbidity burden, suggesting that there may be other mediating factors at play. These may include key social determinants of health that may not be accounted for in our models, including cultural diet, lifestyle behaviors, health literacy, racism and discrimination, and access to transportation.”
- Taparra K, Qu V, Pollom E. Disparities in Survival and Comorbidity Burden Between Asian and Native Hawaiian and Other Pacific Islander Patients With Cancer. JAMA Netw Open. 2022 Aug 1;5(8):e2226327. doi: 10.1001/jamanetworkopen.2022.26327. PMID: 35960520; PMCID: PMC9375163.
