Author: Helen Zhang
Mentor: Dr. Amy Abruzzi
Thomas Jefferson High School for Science and Technology
Lung cancer presents a major public health challenge both in the United States and worldwide. Prominently, it tends to have late diagnoses that result in a higher mortality rate. Asian-American immigrants (AAI) are an underrepresented and homogenized group that may face additional obstacles in being screened for lung cancer and receiving care. These obstacles are sociocultural, financial and economic, and discriminatory in nature. Specifically, many foreign-born Asian-Americans face language barriers and cultural pressures in receiving treatment, and may have additional behavioral risk factors for lung cancer that can be overlooked. Some AAI will struggle financially or lack access to insurance for lung cancer screening and diagnostic procedures, a fact that is obscured by the financial success of other Asian-American ethnic groups. Anti-Asian discrimination in the US also poses an additional barrier to equitable healthcare. The specific relationships between different Asian ethnicities and lung cancer screening is a topic of further exploration.
Keywords: Asian-American immigrants, lung cancer, lung cancer screening, late diagnosis, smoking, language barriers, anti-Asian discrimination
Factors Impacting Lung Cancer Screening and Diagnosis in Asian-American Immigrants
Lung cancer is the deadliest and one of the most common cancers both worldwide and within the United States. Lung cancer refers to cancers that develop in the lung and bronchus, although they may spread to other areas of the body. It tends to have late diagnoses, which contribute to a high rate of mortality (Ellis & Vandermeer, 2011). The average annual rate of incidence of lung cancer from 2015-2019 was 56.3 diagnoses per 100,000 individuals in the US, while the age-adjusted death rate from 2016-2020 was 35 deaths per 100,000, almost twice the next deadliest cancer, female breast cancer (Surveillance Research Program, 2023; American Cancer Society, 2023).
The risk for lung cancer, like risk for all cancers, is determined through both genetic and environmental factors. Notable environmental factors include smoking, a well-known causative agent, as well as exposure to secondhand smoke, asbestos, radon, or air pollution (Malhotra et al., 2016). Primary prevention of lung cancer involves avoiding exposure to these environmental factors, including the cessation of smoking, as well as maintaining a healthy lifestyle.
Lung cancer typically shows few symptoms in stages I and II. Typical symptoms include coughing, chest pain, fatigue, and dyspnea (shortness of breath). Chest pain is typically dull and intermittent, and all symptoms significantly worsen with the spread of cancer (Hyde & Hyde, 1974). Symptoms of lung cancer are not easily distinguishable with other diseases, which means patients are late to seek medical attention and are diagnosed at later stages (Ellis & Vandermeer, 2011). Approximately 75% to 79% of patients are diagnosed at stages III or IV, when cancer has spread significantly, which contributes to the high mortality from this cancer (Blandin Knight et al., 2017; US Preventive Services Task Force, 2021). In the case lung cancer is identified at an early stage, it may be treated with surgical resection of the lung (Blandin Knight et al., 2017).
Lung cancer screening can be detected before the appearance of symptoms in those who are at greatest risk. Annual lung cancer screening with low-dose computed tomography (LDCT) reduces lung cancer deaths in high-risk groups by more than 20% (Lam & Tammemagi, 2021). Currently, the United States Preventive Services Task Force (USPSTF) (2021) recommends yearly LDCT screening for those who are between the ages of 50 and 80 and have a 20 pack-year or more smoking history. Pack-years, which quantify smoking history, are defined as the number of cigarette packs smoked by an individual per day multiplied by the number of years smoked. For example, an individual who has smoked 2 packs a day for 10 years and an individual who has smoked 1 pack a day for 20 years both have a 20 pack-year smoking history and meet the smoking requirement for lung cancer screening. This requirement is in place due to the risks of the screening procedure; cancer screenings can often result in overdiagnosis or in misdiagnosis and the ordering of otherwise unnecessary tests, and CT scans specifically expose the body to a relatively high amount of radiation, although LDCT lowers this risk (US Preventive Services Task Force, 2021; Blandin Knight et al., 2017).
Those with insurance are more likely to receive lung cancer screening, as are those with an existing lung disease (Zahnd & Eberth, 2019). Meanwhile, current smokers, the elderly, and those of lower socioeconomic status are less likely to be screened (Blandin Knight et al., 2017). The USPSTF explains in their 2021 recommendations for lung cancer screening that the guidelines only focus on the two most prominent risk factors, old age and smoking history, but acknowledge that other risk factors exist.
Asian-Americans (AA) are an under-studied group in epidemiology, and are often overlooked or excluded in disparities research. Among racial groups in the United States, Asian-Americans, Americans with ancestry in East or Southeast Asia or the Indian subcontinent, have among the lowest rates of lung cancer incidence—35.8 diagnoses per 100,000 individuals in 2019 compared to 50.6 per 100,000 nationwide (Surveillance Research Program, 2023). Mortality rates for lung cancer in 2019 were 33.4 deaths per 100,000 for all Americans, and 19.1 deaths per 100,000 among Asian-Americans. However, this does not mean that Asian-American groups are not significantly impacted by lung cancer. Unlike other racial groups, cancer typically surpasses heart disease as the leading cause of death in AA, with lung cancer accounting for the largest portion of those deaths (R. J. Lee et al., 2021; Lei et al., 2021; Siegel et al., 2016). The issue of late diagnosis is particularly prevalent among Asian-Americans, who tend to be screened for cancers at lower rates than other American racial groups (Lei et al., 2021; Lee et al., 2021). Asian-American lung cancer mortality varies greatly by sex, with males having higher mortality than females (24.0 vs. 15.4 deaths per 100,000) in 2019 (Surveillance Research Program, 2023).
Foreign born Asian-Americans, or Asian-American immigrants (AAI), specifically have a higher rate of non-small cell lung cancer (NSCLC) and are impacted by additional sociocultural and financial challenges, like access to insurance and a high rate of smoking among foreign-born AA males (Raz et al., 2008; Lei et al., 2021). They are impacted by high lung cancer mortality in their home country: for example, in 2018 there were 43.4 lung cancer deaths per 100,000 men in China. In addition to this, AAI may be unfamiliar with primary and secondary prevention strategies due to the infrequency of such practices in their home countries. For example, in Vietnam, laws controlling tobacco and advocating smoking cessation have had minimal effect, and there are no nationwide programs for lung cancer screening (Tran et al., 2021). These factors make AAI a group that encounters unique obstacles to lung cancer healthcare. This paper explores the barriers Asian-American immigrants face in lung cancer screening and diagnosis.
Literature Review Social, psychological and cultural factors
A major reason why Asian-American immigrants may not seek out care is barriers in language. More than 80% of the foreign-born Chinese and Vietnamese Asian patients fifty years and older in the Boston metropolitan area in Finlay et al. (2002) required an interpreter, suggesting that a language barrier may have caused their delay in seeking medical attention due to avoidance of the challenges posed by such barriers. Over half of foreign-born Asian-Americans exhibit limited English proficiency, but many medical resources are not available in the languages they may speak (Haley et al., 2022). The diversity of languages Asian immigrants speak leads to great difficulty accommodating everyone. In many areas, language barriers are not easy to overcome due to many hospitals having poor access to interpreters, helping to explain such a delay (Haley et al., 2022). This problem of language barriers is further compounded by the fact that lung cancer risk increases with age and so does the need for screening based on smoking history. In 2019, the incidence rate for those ages 65 and over 298.3 cases per 100,000, more than 4 times the rate for ages 50-64 and almost 6 times the incidence rate across all ages (Surveillance Research Program, 2023). Older adults have a harder time learning a new language, and those who immigrate to the US later in life are less likely to speak English “very well” (Stevens, 1999). This increases the chance of older immigrants encountering language barriers in medical settings. Therefore, while many cases of lung cancer in the Asian-American population are among older adults, they are the group that may encounter the most difficulty in receiving care.
Compared with native-born Asian-Americans, foreign-born Asian-Americans have a lower proportion of former smokers (18.8% vs. 9.6%) but a higher proportion of current smokers (12.4% vs. 13.6%) (Huh et al., 2007). This indicates that there may be cultural factors contributing to the development or continuation of smoking behavior among Asian immigrants. Indeed, Asian-Americans are less likely to seek help to quit smoking and are the American racial group with the second-lowest smoking cessation rate (Lei et al., 2021). The proportion of men who smoke in South and Southeast Asia is very high (Sreeramareddy et al., 2014). This pattern continues in Asian diaspora: by sex, Asian-American men smoke at much higher rates than Asian-American women (13.5% vs. 5.0%), a greater difference than in the general American population (13.1% vs. 10.1%) (Ra et al., 2022; Office on Smoking and Health, 2023). This contributes to the appearance of a lower rate of smoking, even though AA males smoke more than the general population (Lei et al., 2021).
Despite the fact that Asian-American women tend to have low rates of smoking, lung cancer incidence among some groups, like Chinese-American women, remain high. This is likely due to cultural practices like the prevalence of smoking among Asian men, leading to exposure to secondhand smoke in home countries before immigration (needs a reference). This is especially significant for immigrants because lung cancer risk from secondhand smoke is greater while the lung is developing before age 25, and consequently immigrants are exposed to environments with secondhand smoke earlier in their lives and before immigration (Asomaning et al., 2008). In addition, women tend to cook in many Asian cultures. Chinese and Malay cooking styles, which typically involve high-temperature frying and stir-frying, lead to high exposure to carcinogenic cooking oil fumes (Lee & Gany, 2012). Other related cooking styles presumably carry a similar risk.
In addition to this, there may be a self-imposed mindset of being able to handle symptoms of lung cancer on one’s own, and viewing the seeking of medical attention as potentially disruptive to one’s image as a docile, hardworking citizen who does not complain—Asian-American immigrants may view going to a doctor as a sign of failure to live up to those standards (Lee et al., 2021). Lee et al. states that this mindset is likely influenced by the supposed image of Asian-Americans as a “model minority”.
Financial and insurance barriers
Wealth disparities across Asian-Americans are not apparent in aggregated data, which masks differences between groups. Although AA typically rank higher in income than many other racial/ethnic groups, in reality some Asian-American groups have much lower income than others. For example, Indian-American households tend to have much higher incomes than Hmong American households, and some groups, like the Filipino population, have a large proportion under the federal poverty line (Gomez et al., 2014; Islam et al., 2010). Immigrants in particular tend to have lower incomes than their US-born counterparts (Ahmmad et al., 2020).
In general, immigrants to the United States are less likely to have health insurance and more likely to be financially unstable (Hamilton, 2015). This obstructs access to secondary prevention of lung cancer, especially since those on Medicare may experience difficulty getting coverage for LDCT (Expanded access to CT lung cancer screening in Medicare, 2021). An uncertain financial situation can lead to unwillingness to seek medical interventions such as cancer screening (Adamson et al., 2003).
Within the field of public health, there is a tendency for Asian-Americans to be homogenized. Labels like “Asian-American” or “AAPI” are extremely broad, and obscure the diversity within this group, masking important differences. Ethnicities under this label vary greatly in income, education, and access to health care. Asian-American immigrants in particular face additional challenges, having lower levels of education and household income overall compared to native-born Asian-Americans (Ahmmad et al., 2020).
The view of Asian-Americans overall in healthcare, especially immigrants due to the existence of a “healthy immigrant effect” or “immigrant health paradox” (Hamilton, 2015), is generally that they are a low-risk, low-priority population. In reality, this leads to a deficit in meeting Asian-American immigrant health needs. Low incidence rates of lung cancer are dismissed, even if they potentially indicate a lack of screening or seeking of medical assistance.
Anti-Asian sentiment in the United States may also affect health outcomes. Historical anti-Asian sentiment is associated with stress among Asian-Americans, negatively impacting general health and potentially increasing cancer risk (Soung & Kim, 2015; Office on Smoking and Health, 2022). This can compound stress from other sources, like financial difficulties immigrants might encounter. An increase in stress is also associated with an increase in smoking, directly contributing to lung cancer (Office on Smoking and Health, 2022). The COVID-19 pandemic saw a significant increase in anti-Asian racism, increasing stress for Asian-Americans while aggravating perceived bias, decreasing the willingness to seek cancer care (R. J. Lee et al., 2021). This means that the racism Asian-American immigrants may experience increases their risk for lung cancer.
Asian-American immigrants face a complexity of challenges in the area of lung cancer healthcare. These challenges include language barriers and cultural pressures in receiving screening and treatment. AAI struggle to quit smoking, and they face risk factors for lung cancer like exposure to cooking oil fumes or childhood exposure to secondhand smoke in their home countries. Many struggle financially or lack insurance coverage, while the aggregation of Asian-American ethnic groups obscures significant economic disparities. This aggregation of data also causes medical professionals to overlook risk factors and ignore AAI patients’ needs. AAI also face mental health challenges that compound cancer risk, especially with the increase in anti-Asian racism in the wake of the COVID-19 pandemic. The considerable inequity Asian-American immigrants are confronted by in lung cancer care needs to be addressed. Understanding this complex public health issue is key to inclusive and equitable lung cancer care.
The specific relationships between different Asian-American ethnic groups and lung cancer are worth investigating in much greater detail. Asia spans a wide variety of cultures and nations that each have their own distinct cultural practices in relation to smoking and other lung cancer risk factors, as well as different historical relations to the United States, leading to incredibly variable circumstances of immigration and consequently wide variation in social determinants of health. Understanding risk factors and access to lung cancer care in specific Asian-American ethnic groups is essential to providing culturally-sensitive lung cancer interventions and addressing healthcare needs in this overlooked group.
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