Transcript Presentation - Center for Comparative Immigration Studies

Social disparities in cancer
among Mexican women living in
Mexico and in the United States
Gloria Giraldo, MPH
DrPH Program
School of Public Health
UCLA
Proposed “cancer disparity”
definition by Nancy Krieger (2005)

'Social disparities in cancer refer to health inequities spanning the
full cancer continuum, across the lifecourse.

These cancer disparities involve social inequalities in the prevention,
incidence, prevalence, detection and treatment, survival, mortality,
and burden of cancer and other cancer related health conditions
and behaviors.

They arise from inequities involving, singly and in combination,
adverse working and living conditions and inadequate health care,
as linked to experiences and policies involving socioeconomic
position (e.g., occupation, income, wealth, poverty, debt, and
education) and discrimination. This discrimination, both institutional
and interpersonal, can be based on race/ethnicity, socioeconomic
position, gender, sexuality, age, language, literacy, disability, immigrant
status, insurance status, geographic location, housing status, and
other relevant social categories.'
Cancer disparities in the U.S.

Since the early 20th century, substantial
socioeconomic and racial/ethnic
disparities in breast and cervical cancer
incidence, survival and mortality have
been documented in the United States
(US) (Krieger, 2005).
Latinas are diagnosed with cervical cancer almost
twice as often as non-Latina White women.



Saraiya and colleagues (2007) reported that
the incidence rate declined from 10.2 cases
in 1998 to 8.5 in 2002 for the entire
population, the average annual incidence rate
was highest among Latinas (14.8).
The incidence of cervical cancer for all
groups between 1998 and 2003 was 8.9.
Furthermore, the overall cervical cancer
mortality rate was 2.7 and the median age of
death was 57; for Latinas the rate was 3.4
and the median age was 51.
Mexican immigrant women
A study that examined nativity status and prevalence of
cervical cancer screening found that 17% of immigrant
women from Mexico who have lived more than 25% of their
lives in the US have never been screened for cervical cancer.
 32% of those who have lived in the US less than 25% of
their lives have never been screened (4).
 Remarkably, 55% to 60% of cervical cancer cases arise in
women that are never or rarely screened (5).
 To put these numbers in perspective, the Healthy People
2010 goal for women over 18 for ever having a Pap test is
97%. Currently, the rate of ever having a Pap test for Latinas
in general is 88%; however, low-income immigrant Mexican
women lag behind the national screening goal potentially by
as much as 29 percentage points (6).

Screening plays a pivotal role

A robust body of literature has
established that advanced stage diagnosis,
shorter survival and higher mortality due
to cervical cancer among Latinas are
largely due to inadequate or lack of
screening.
The picture in Mexico
International data from the 1980s showed
that Mexico had the highest cervical cancer
mortality rates among fifty countries from
three continents (Europe, the Americas and
Asia) (Boring, 1992). Mexico’s mortality rate
in 1986 was 14.7.
 In 1989 it climbed to its highest level 16.1
per 100,000.
 In 2006, cancer mortality rate had decreased
to 9.9.

The picture in Mexico

Cervical cancer mortality risk is three
times higher in rural areas, as compared
to urban zones, and women living in
states where socio-economic
development is lower have the highest
mortality risks, as compared with women
living in Mexico City (LazcanoPonce,2003)
Breast Cancer in Mexico



Breast cancer mortality rates in Mexico
show a substantial increase in the last five
decades.
Between 1955 and 1960, data on breast
cancer show 4 deaths per 100,000 women.
It then increased to approximately 9 per
100,000 and has remained somewhat stable
since then.
Breast cancer is responsible for a high
number of premature deaths since 60% of
deaths are in women between the ages of 30
and 59.
Breast cancer in U.S. Latinas

Although breast cancer rates are lower in
Latinas than in Non-Latina White women in
the U.S., published data indicate that the
disease presentation among Latinas includes:
Earlier age at diagnosis, larger tumor size,
more advanced stage, higher proportion of
adverse prognostic indicators, co-morbidities,
poorer overall survival (Howe HL, Wu X, Ries
LA, et al, 2006).
Objective

My dissertation will explore social
disparities in cancer screening rates and
cancer-related behaviors among Mexican
women living in Mexico and in the United
States taking into consideration health
system variables in both countries.
Implication

Understanding cancer screening trends
and cancer related behaviors of Mexican
women in the larger binational context
may shed new light on the social
processes that influence cancer screening
disparities in the US with implications for
public health practice and theory
refinement in the field of cancer control.

Studying breast and cervical cancer
screening binationally is of
paramount importance because
Mexico is currently experiencing a
cancer epidemiological transition
Rationale

In the realm of cancer research, the type of
cancer screening programs in the place of
origin, cancer knowledge or educational
campaigns, the type of access to screening
and to cancer care, and preventive health
behaviors are all contextual variables that
will impact the type of knowledge, attitudes
and experiences with which the immigrant
woman arrives to her new destination and
influence her ability to navigate her new
healthcare context.
Aim

To compare cancer screening rates and
prevalence of cancer-related behaviors
and health services variables (healthcare
coverage and access) of Mexican women
of different socioeconomic backgrounds
living in Mexico and in the United States.
Data

Encuesta Nacional de Salud y
Nutrición (ENSANUT 2006) (Mexico’s
National Health and Nutrition Survey).
Comprehensive health and nutrition
surveys have been conducted in Mexico in
the last 20 years. ENSANUT 2006 is the
third national survey of this nature.
California

California Health Interview Survey
2007 – The California Health Interview
Survey (CHIS) is a population-based
telephone survey of California’s population
conducted every other year since 2001.
CHIS is the largest health survey conducted
in any state and one of the largest health
surveys in the nation. This survey contains
the largest sample of Mexican-origin
individuals in the United States.
Variables
Independent variables:
 Socioeconomic related questions
(education, income, poverty level, rural vs.
urban)
 Language use and health literacy
questions (and length of residence in the
US for CHIS only)
 Health coverage
 Reproductive health-related questions
Dependent variables
General health condition
 Pap-smear related questions
 Mammogram-related questions
 Smoking and drinking related questions
 Fruit and vegetable consumption
questions
 Exercise related questions

Statistical Analyses

I will initially estimate the reported Pap
test and mammography screening rates by
age, socioeconomic status, educational
attainment as well as other demographic,
and health-related individual-level
covariates in bivariate analyses.
Statistical Analyses

A test of association will assess the
overall statistical significance of each
potential factor, such as the association of
employment or health insurance status
with Pap test and mammography use,
after adjusting for age
Statistical analyses
Conduct multivariate logistic regression analyses to adjust
for factors indicated from the bivariate analysis to have a
significant association with Pap test or mammography
screening rates, and use adjusted Wald F tests to determine
the significance of the model covariates.
 At first, I expect to obtain intermediate reduced models that
will include significant individual-level covariates or factors
related to the Pap test and mammography screening
outcomes.
 I will test for potential two-way interaction terms. Finally,
reduced models will include all socioeconomic covariates,
and all other significant individual-level main effects, to
provide fully adjusted screening estimates for the Pap test
and mammography screening outcomes and other cancerrelated health behaviors.

Limitations

The main limitations of this study are
inherent to international comparisons
utilizing two different sources of data with
different data collection methodologies.
However, at this point in time, there are no
binational studies on cancer screening.
Therefore, this study will highlight the need
to not only conduct a binational cancer
study but will promote an agenda of
binational collaboration in cancer control.