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

IMPORTANCE Improper 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. OBJECTIVE 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. DESIGN, SETTING, AND PARTICIPANTS This 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.


Introduction
Native Hawaiian and other Pacific Islander individuals are frequently aggregated with Asian individuals or excluded altogether in medical research. 1,2This is despite federal guidelines separating data for Native Hawaiian and other Pacific Islander individuals from data for Asian individuals. 3Native Hawaiian and other Pacific Islander individuals share ancestry from nearly 30 island nations across Melanesia, Micronesia, and Polynesia and experience dissimilar health disparities, including higher rates of diabetes, obesity, asthma, and cardiovascular diseases, compared with Asian individuals. 2reover, 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.This paucity of medical research masks existing disparities, which can influence public policy and funding allocation. 2 Cancer is the leading cause of death for the Asian, Native Hawaiian, and other Pacific Islander population in the United States. 42][13] 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.

Study Design
This cohort study was deemed exempt from review and informed consent by the Stanford University institutional review board because data were deidentified and publicly available.This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Setting
Asian, Native Hawaiian, and other Pacific Islander patients with cancer in the United States between January 1, 2004, and December 31, 2017, were evaluated.Data were collected from the National Cancer Database (NCDB), a hospital-based, comprehensive data set that captures more than 70% of all newly diagnosed malignancies in the United States. 14

Participants
The 9 most common malignant neoplasms in the United States evaluated were breast, lung, prostate, colorectal, kidney or bladder, lymphoma, melanoma, endometrial, and oral cavity cancers.

Variables
The primary end points for comparison were OS and Charlson-Deyo Comorbidity Index (CCI).OS was defined as months from initial diagnosis to date of last contact or death.CCI is a weighted index that accounts for patient comorbidity number and severity. 14

Data Sources and Measurements
Patient covariables included age (years), miles between patient zip code or city centroid and the hospital, zip code-based income (above vs below median), rurality (urban or rural vs metropolitan), zip code-based education (above vs below median), insurance status, comorbidity burden (CCI Յ2, indicating lower comorbidity burden, vs CCI Ն3, indicating higher comorbidity burden), facility type, and US region.Socioeconomic status variables were estimated based on census-level data.Patients with missing data were included and reported accordingly.

Statistical Analysis
Patient characteristics were reported as number and frequency for categorical variables and median (IQR) for continuous variables.OS was analyzed with Kaplan-Meier estimates and compared using log-rank tests.Multivariable logistic regression assessed high CCI comorbidity burden with adjusted odds ratios (aORs) and multivariable Cox proportional hazard assessed OS with adjusted hazard ratios (aHRs), both with 95% CIs.All regression analyses controlled for patient and disease confounding characteristics to limit bias.Both the logistic regression outcome and covariable for CCI were coded as lower vs higher comorbidity burden.Proportional hazards assumptions were tested.
Covariables that violated the proportionality assumptions were fit to the model with stratification.All

Patient Characteristics
Of

tests were 2 -
tailed with statistical significance set at P = .05unless stated otherwise.All statistical analyses were conducted using R statistical software version 4.0.3 in RStudio version 1.3.1093(R Project for Statistical Computing).Data were analyzed from January to May 2022. 15

Table .
Demographic and Clinical Characteristics of Asian, Native Hawaiian and Other Pacific Islander, and Non-Hispanic White Patients Diagnosed With the 9 Most Common Cancers in the United States (continued) Figure 1.Multivariable Logistic Regression of Comorbidity Burden for Asian and Native Hawaiian and Other Pacific Islander Patients With Cancer Disparities Between Asian and Native Hawaiian and Other Pacific Islander Patients With Cancer Asian patients, and 19% among Southeast Asian patient (Table).Figure 2 displays unadjusted Kaplan Meier survival curves.After adjusting for confounders, including comorbidity burden, most Asian groups (19 of 27 groups [70%]) demonstrated superior OS compared with White patients: 7 of 9 cancers among East Asian patients, 6 of 9 cancers among South Asian patients, and 6 of 9 cancers among Southeast Asian patients (Figure3).The only Asian group with inferior OS compared with White patients was Figure 2. Kaplan-Meier Estimates for Overall Survival Probability for Asian and Native Hawaiian and Other Pacific Islander (NHPI) Patients With Cancer JAMA Network Open | Diversity, Equity, and Inclusion JAMA Network Open.2022;5(8):e2226327.doi:10.1001/jamanetworkopen.2022.26327(Reprinted) August 12, 2022 5/9 Downloaded From: https://jamanetwork.com/ on 09/24/2023