Liver cancer control interventions for Asian Americans: A first community-based program project to reduce cancer health disparities

PL04-03

“Liver Cancer Control Interventions for Asian Americans” is the first NIH/National Cancer Institute/Center for Reducing Cancer Health Disparities-funded program project (P01) and the first P01 that emerged from a Special Populations Network or Community Network Program cooperative agreement recipient. Funded in September, 2006 for a five-year period, this P01 has as its overall goal increasing the proportion of Asian American adults from three ethnic groups to be serologically tested for the hepatitis B virus (HBV). HBV is the carcinogenic agent responsible for 80% of the liver cancer among Asian Americans and the reason that HBV-induced liver cancer is the most significant cancer health disparity affecting Asian Americans. This presentation will examine how our research focuses on the (1) populations at high risk for hepatitis B-induced liver cancer in the communities where they reside; (2) the problem posed by hepatitis B-induced liver cancer; (3) our process for conducting this community-based research through our three projects and three supporting cores; (4) our plan that exemplifies the interdependence and iteration between academia and community; and finally, (5) the prospects or expected contributions to the science of cancer health disparities that will be achievable.
 Our three projects focus on three Asian American populations which have liver cancer incidence rates that are considerably higher than those affecting non-Hispanic whites. These are Vietnamese (Project 1), Hmong (Project 2), and Korean (Project 3) Americans. Among U.S. racial/ethnic populations, Vietnamese Americans have the highest male incidence rate of liver cancer (41.8 per 100,000), and Korean Americans experience the highest female incidence rate of liver cancer (10.0 per 100,000). Hmong Americans have incidence rates intermediate between Vietnamese and Koreans (25.7 per 100,000 for males and 8.8 per 100,000 for females). By contrast, the comparable incidence rates for non-Hispanic whites are substantially less at 3.7 per 100,000 for males and 1.5 per 100,000 for females. While the annual incidence rates for the majority of other cancers in the United States decreased between 1995-2004, annual liver cancer incidence rates increased between 1995-2004 by 2.2% per year (p<.05), a growth rate exceeded only by thyroid cancer. Furthermore, liver cancer mortality rates increased between 1995 to 2004, by 1.7% per year (p<.05) far exceeding the annual rate of increase of any other cancer site.
 The problem posed by HBV-induced liver cancer in the United States not only includes its pre-eminence as the cancer site with the highest annual increase in mortality rates; its rank order of having the second highest increase in annual incidence rates; but also in its dismally poor prospects for treatment and survival. While treatment options are increasing and improving, the five-year survival rate remains at less than 10%. Thus, liver cancer incidence rates closely mirror mortality rates.
 All three of these populations are primarily first generation immigrants, many of whom prefer speaking languages other than English; and typically retain many of the cultural values of the lands of origin that are different than those of mainstream Americans. Thus, in addition to experiencing the heaviest burden of HBV-induced liver cancer, these populations also encounter socio-cultural and linguistic barriers to accessing health care.
 The process leading to our initiating this research has been one that has required years of work to develop collaborations with our communities and their leaders. All of the academic researchers leading this P01 have had considerable prior experience in working with Asian American communities and have been individually effective. A common venue for both academic researchers and community leaders has been and continues to be the Asian American Network for Cancer Awareness, Research and Training (AANCART), a NCI-funded cooperative agreement that most of us have participated in since 2000. Thus, the process was enabled because of the trust that was earned and the years of working together with our community partners that were facilitated by AANCART. Ultimately, the process produced a funded P01 tied together by a common overall goal of increasing the proportion of Asian American adults being serologically tested for HBV.
 Our plan was built upon AANCART’s populations of emphases in the three localities and through three projects. Tung Nguyen, M.D. of the University of California, San Francisco (UCSF) leads Project 1, “Promoting Hepatitis B Screening for Vietnamese American Adults”. Moon Chen, Jr., Ph.D., M.P.H. of the University of California, Davis (UCD) leads Project 2, “Community-based Hep B Intervention for Hmong Adults” in collaboration with May Ying Ly of the Hmong Women’s Heritage Association; Roshan Bastani, Ph.D., of the University of California, Los Angeles (UCLA) leads Project 3, “Increasing Hep B screening among Korean church attendees” in collaboration with Vicky Taylor, MD, of the Fred Hutchinson Cancer Research Center, Seattle, Washington.The three cores reflected strengths that offer inter-project standardization as well as specialized expertise and are respectively directed by Moon Chen, Jr. (UCD) Administration Core; Susan Stewart, Ph.D. (UCSF), and Annette Maxwell, Dr.P.H. (UCLA). We have chosen the Health Behavior Framework as the conceptual guide in developing interventions.
 Taken as an integrated program project, our goals and abbreviated objectives are as follows:
 (1)
 Conduct community-based research interventions focused on reducing hepatitis B-induced cancer morbidity and mortality within three Asian American populations.
 a.
 Characterize hepatitis B knowledge levels and receipt of hepatitis B screening among three Asian American ethnic groups.
 b.
 Develop and implement ethnically-specific interventions to increase Hep B testing rates in our populations.
 c.
 Evaluate the effectiveness of these interventions
 (2)
 Analyze both quantitative and qualitative data and lessons learned across projects.
 (3)
 Report progress and share findings.
 The interventions in each project are culturally targeted and responsive to the historical, social, and economic context relevant for each population. The projects share some common research design elements in that each project begins with the collection of baseline data, follows with division into intervention and control groups; and ends with assessing the differences between intervention and control groups with respect to the common metric of increasing serological testing for HBV. The projects also share common eligibility criteria, and benefit from cores that enhance the inter-project interactions and synergies across the projects.
 Indeed, we believe the whole of our P01 is greater than the sum of our parts as we engage in very frequent communications (e-mails; listserves; scheduled conference calls; and regular meetings within projects and an annual face-to-face leadership meeting with the NIH Project Officer) that confer mutual benefits across projects and cores. At this point, we have agreed on questions that would be asked in all baseline surveys as well as customizing questions that are specific for our respective populations; standardized processes for validating translation of questionnaire items from English to Vietnamese, Hmong, and Korean; and engaged in considerable pilot-testing of items both in the field and with key informants. Our research designs reflect the harmonization of scientific rigor with community realities along with meeting the challenges of conducting linguistically appropriate and culturally competent interventions.
 Hence, in terms of prospects, we are convinced that our P01 will not only contribute empirically to the understanding of interventions to reduce cancer health disparities in three Asian American communities, but that the process and results will inform interventions for other U.S. populations. Additionally, our P01 research team includes doctoral-level Vietnamese, Hmong, and Korean Americans who are bilingual and bicultural. We include junior researchers in our team who are either Asian American or have in interest in working in these populations. Hence, while conducting disparities research, we are also training doctoral level individuals from affected populations.
 This P01 targets the most significant cancer health disparity affecting Asian Americans. In the U.S., about 1.25 million people are chronically infected with hepatitis B. HBV infections occur disproportionally in all people of color in comparison to non-Hispanic Whites. Chronic hepatitis B is extremely dangerous because it can lead to liver cancer and other health problems. Undiagnosed and untreated, HBV infection robs lives. We are grateful to have the privilege of launching this community-based intervention towards reducing a critical cancer health disparity with an outstanding team of scientists and community partners.
 This research is funded through P01CA109090-01A jointly by the National Cancer Institute and the National Center on Minority Health and Health Disparities, NIH. The contents of this presentation are the responsibility of the presenters and do not necessarily reflect the views of the NIH.