Abstract
Background:
US-born Latinos have a higher incidence of hepatocellular carcinoma (HCC) than foreign-born Latinos. Acculturation to unhealthy lifestyle behaviors and an immigrant self-selection effect may play a role. In this study, the authors examined the influence of generational status on HCC risk among Mexican American adults.
Methods:
The analytic cohort included 31,377 self-reported Mexican Americans from the Multiethnic Cohort Study (MEC). Generational status was categorized as: first-generation (Mexico-born; n = 13,382), second-generation (US-born with one or two parents born in Mexico; n = 13,081), or third-generation (US-born with both parents born in the United States; n = 4914). Multivariable Cox proportional hazards regression was performed to examine the association between generational status and HCC incidence.
Results:
In total, 213 incident HCC cases were identified during an average follow-up of 19.5 years. After adjusting for lifestyle and neighborhood-level risk factors, second-generation and third-generation Mexican Americans had a 37% (hazard ratio [HR], 1.37; 95% confidence interval [CI], 0.98–1.92) and 66% (HR, 1.66; 95% CI, 1.11–2.49) increased risk of HCC, respectively, compared with first-generation Mexican Americans (p for trend = 0.012). The increased risk associated with generational status was mainly observed in males (second-generation vs. first-generation: HR, 1.60 [95% CI, 1.05–2.44]; third-generation vs. first-generation: HR, 2.08 [95% CI, 1.29–3.37]).
Conclusions:
Increasing generational status of Mexican Americans is associated with a higher risk of HCC. Further studies are needed to identify factors that contribute to this increased risk.
Keywords: acculturation, cohort, generational status, hepatocellular carcinoma, Mexican Americans
INTRODUCTION
The Latino population is the largest minoritized racial and ethnic group in the United States and continues to grow. In 2020, there were more than 62.1 million Latino individuals residing in the United States, representing a 23% increase since 2010.1 The most recent and available US Census data from 2010 show that Mexican individuals constituted 63% of the Latino population in the United States, representing the largest subpopulation from Latin American countries.2
Epidemiologic trends in 2009–2019 indicate that Latino men and women have an increasing incidence of liver and intrahepatic bile duct cancer.3 Our previous study in the Multiethnic Cohort Study (MEC) showed that nativity (i.e., birthplace) is associated with hepatocellular carcinoma (HCC) incidence among Latinos even after adjusting for important risk factors.4 US-born Latinos have a 45% (hazard ratio [HR], 1.45; 95% confidence interval [CI], 1.08–1.96) increased risk of developing HCC compared with foreign-born Latinos.4 In addition, data from the California Cancer Registry indicate that foreign-born Latinos have an HCC incidence rate almost one half that of Latino individuals born in the United States.5,6
A phenomenon known as the immigrant health paradox could contribute to the superior physical health of immigrants residing in the United States compared with individuals born in the United States, despite a lower socioeconomic status (SES) and experiencing barriers to medical care.7 First introduced as an epidemiologic paradox by Markides and Coreil, Southwestern Hispanic individuals, particularly by the US–Mexico border, have lower mortality rates compared with non-Hispanic White individuals.8 An immigrant self-selection effect could explain these trends, whereby those immigrating to the United States typically are healthier than those who remain in their country of origin and also those born in the US.9 Another potential explanation is acculturation, or the process whereby immigrant populations assimilate to different lifestyle behaviors, cultural norms, and values from their country of origin.10 These lifestyle behaviors may include unhealthy diet,11 uptake of cigarette smoking,12–14 increased alcohol consumption,14,15 or even increased physical activity.16
Acculturation to US norms (e.g., alcohol use, obesity, diabetes) in successive generations may contribute to increasing HCC incidence among the Latino population as the US-born population grows. In our previous study, we demonstrated that nativity is an important factor influencing HCC risk.4 In the current study, we further disaggregated US-born Mexican Americans to understand whether generational status influences risk, which may better capture processes of acculturation and potential impact of cultural influences on lifestyle behaviors. In addition, we assessed the impact of neighborhood factors in our analyses. Thus, in this prospective study, we assessed the association of generational status with HCC risk among Mexican American adults and evaluated heterogeneity in association with known HCC risk factors, such as diabetes, obesity, alcohol intake, smoking status, and neighborhood-related factors.
MATERIALS AND METHODS
Study population
The MEC is a prospective cohort established in 1993–1996 that has recruited more than 215,000 participants living predominantly in Los Angeles County, California, and Hawai`i. Study design and details have been described previously.17 Briefly, participants self-reported five major racial and ethnic groups: African American/Black, Japanese American, Latino, Native Hawaiian, and White. At baseline, a 26-page mailed questionnaire, available in English and Spanish, was completed by all participants, with detailed questions including demographic and lifestyle behaviors. In our study of the MEC California component, we excluded participants who did not self-identify as Mexican American (n = 180,087) or had missing smoking status (n = 1126), no body mass index (BMI) data (n = 244), invalid diet information because of implausible total energy intake or food components (e.g., alcohol intake and coffee consumption; n = 1379), missing parental place of birth information (n = 576), or residential address with poor geocoding precision (n = 902). Our final analytic sample consisted of 31,377 Mexican Americans. Study protocols were approved by the Institutional Review Boards of the University of Southern California and the University of Hawai`i. Participants were considered to have provided consent by returning a mailed questionnaire as approved by the University of Hawai`i and the University of Southern California Institutional Review Boards.
Generational status
Our analytic sample focused on Mexican American adults because they represent the largest Latino heritage in the MEC (74.9%). This aligns with 1990 US Census data showing that the Mexican population in California constituted 80% of the Latino population.18 Among Mexican Americans in the MEC, we used self-reported participant and parental birthplace to determine generational status, as described in previous studies.19–21 Participants were considered first-generation if they were born in Mexico with both parents born in Mexico, second-generation if they were born in the United States with at least one parent born in Mexico, and third-generation (or greater) if they were born in the United States with both parents also born in the United States. We hypothesized that greater acculturation (i.e., with successive generations) would correspond with increased HCC risk, so first-generation Mexican American adults served as our reference group.
Cancer ascertainment
The MEC regularly performs linkages with the National Cancer Institute’s Surveillance, Epidemiology, and End Results statewide registries of California and Hawai`i. These linkages capture the majority of cancers because out-migration in the MEC to other states is very low (3.7%). A participant was considered to have HCC using the International Classification Disease, third edition histology code C220 and morphology codes 8170–8175. Cases were identified from baseline through December 31, 2017. Information on tumor stage at diagnosis (localized, advanced [regional and distant], or unknown) was available from Surveillance, Epidemiology, and End Results registries.
Covariate data
In the baseline questionnaire, participants were asked about intake of 180 food items in a quantitative food frequency questionnaire as well as demographic information, health behaviors, and medical conditions. Participants self-reported weight (pounds or kilograms) and height (feet and inches or centimeters), which were used to calculate BMI (kg/m2). In addition, participants were asked whether they ever smoked ≥20 packs of cigarettes in their lifetime. Responses were “no”; “yes, but I quit smoking”; or “yes, and I currently smoke”; and responding participants were classified as never, former, or current smokers, respectively. Alcohol intake in the past year was measured by type of beverage (regular or draft beer, light beer, white or pink wine, red wine, hard liquor), frequency (from never or hardly ever to four or more times per day), and intensity per their usual serving (from less than one can/glass/drink or bottle to four or more cans/glasses//drinks or bottles). Ethanol intake per day was calculated using the following conversions: one can of regular/draft beer = 13.0 g of ethanol; one can of light beer = 11.5 g; one glass of white/pink wine = 11.3 g; one glass of red wine = 11.2 g; and one drink of hard liquor = 15.4 g. The baseline questionnaire also asked about the average number of cups of coffee consumed per day and whether a participant had ever been told by a physician that they have diabetes (high blood sugar).
Address geocoding and neighborhood-level information
Residential baseline addresses were geocoded using ArcGIS Pro 2.8.2 and ESRI StreetMap Premium version 2020 R4 (both from ESRI) to latitude and longitude coordinates of rooftop or parcel centroid.22 Census block groups were used as the neighborhood unit. A composite ethnic enclave index was created by principal component analysis of indicator variables at the census block group.23 Indicator variables for ethnic enclave included percentage who are Hispanic, percentage foreign-born Hispanic, percentage with limited English proficiency who speak Spanish, and percentage of linguistically isolated households that speak Spanish.24 Ethnic enclave was categorized into quintiles (Q) across census block groups in Los Angeles County, from Q1 (representing the least ethnically/culturally distinct) to Q5 (representing the most ethnically/culturally distinct). In addition, neighborhood SES (nSES) was determined by principal component analysis based on education, occupation, unemployment, household income, poverty, rent, and house value.25 nSES was categorized into quintiles based on the distribution across census block groups in Los Angeles County.26
Statistical analysis
Baseline demographic and lifestyle behaviors for Mexican Americans were reported by generational status as counts with frequencies for categorical variables and as means with standard deviations for continuous variables. We estimated incidence rates for each generation group in the MEC, with age standardization to the 2000 US Census standard population and truncated at age 45 years. Left-truncated Cox proportional hazards models of HCC were fit to estimate HRs with 95% CIs for the association with the primary exposure of generational status. Age (in days) was used as the underlying time metric from baseline to the earliest end point of HCC diagnosis, death, or study closure (December 31, 2017). Covariates of interest included age at cohort entry, sex (male, female), BMI (<25, 25–29.9, ≥30 kg/m2), smoking status (never, former, current), alcohol intake (none, <12 g/day, ≥12 g/day), history of diabetes (yes, no), daily coffee consumption (zero, one, two or three, or four or more cups per day), ethnic enclave (quintile), and nSES (quintile). Data were also adjusted for clustering by census block group to account for correlation structure. The proportional hazards assumption was met for each covariate based on Schoenfeld residuals. We also assessed quintiles of the Healthy Eating Index-2015, maize consumption (fresh/frozen/canned corn and corn tortillas/muffins/bread), and pack-years of cigarette smoking in our models, but these did not improve model fit and thus were not included in our regression models. However, we included distributions of these variables in Table 1. Generation was parameterized as indicator variables for the second and third generations, with the first generation as reference. Tests for trend were calculated across generations, parametrized as continuous variables (first generation = 1, second generation = 2, third generation = 2.5). Because the first is foreign-born and the second and third generations are US-born, the coding generations as 1, 2, and 2.5 reflected such nativity differences. We also performed stratified analyses by sex as well as diabetes status, BMI, alcohol intake, smoking status, nSES, and ethnic enclave. Tests for heterogeneity were assessed using the Wald statistic for cross-product terms of trend variables for BMI, diabetes status, alcohol intake, smoking status, ethnic enclave, and nSES. Ethnic enclave and nSES were transformed to dichotomous variables for heterogeneity tests given the small case counts across quintiles (Q1–Q3, nonenclave; Q4–Q5, enclave; Q1–Q3, low nSES; Q4–Q5, high nSES).5,27 A percent change for each unit increase in generational status was calculated as (1 − HR)*100 associated with the test for p for trend. All p values were two-sided, and p < .05 was considered statistically significant. For all analyses, the SAS 9.4 statistical software package was used (SAS Institute Inc.).
TABLE 1.
Distribution of sociodemographic and physical health characteristics by generation of Mexican Americans in the Multiethnic Cohort Study, N = 31,377.
| No. (%) | |||
|---|---|---|---|
|
| |||
| First-generation, n = 13,382 | Second-generation, n = 13,081 | Third-generation, n = 4914 | |
| Age at cohort entry: Mean ± SD, years | 58.7 ± 7.8 | 62.4 ± 7.1 | 57.8 ± 8.0 |
| Sex | |||
| Male | 6913 (51.7) | 6461 (49.4) | 2295 (46.7) |
| Female | 6469 (48.3) | 6620 (50.6) | 2619 (53.3) |
| Body mass index by category, kg/m2 | |||
| <25.0 | 3447 (25.8) | 3621 (27.7) | 1344 (27.4) |
| 25.0–29.9 | 6579 (49.2) | 5858 (44.8) | 2101 (42.7) |
| ≥30.0 | 3356 (25.1) | 3602 (27.5) | 1469 (29.9) |
| Smoking status | |||
| Never | 6905 (51.6) | 6082 (46.5) | 2091 (42.6) |
| Former | 4586 (34.3) | 5321 (40.7) | 1955 (39.8) |
| Current | 1891 (14.1) | 1678 (12.8) | 868 (17.7) |
| Pack-years of cigarette smoking: Mean ± SD | 11.4 ± 12.3 | 13.0 ± 13.6 | 13.5 ± 13.8 |
| Alcohol intake, grams/day | |||
| None | 7166 (53.6) | 6393 (48.9) | 2269 (46.2) |
| <12 | 5279 (39.5) | 5392 (41.2) | 2111 (43.0) |
| ≥12 | 973 (7.0) | 1296 (9.9) | 534 (10.9) |
| History of diabetes | |||
| Yes | 2079 (15.5) | 2382 (18.2) | 832 (16.9) |
| Daily coffee consumption, cups per day | |||
| 0 | 4235 (31.7) | 3362 (25.7) | 1208 (24.6) |
| 1 | 6876 (51.4) | 6411 (49.0) | 2299 (46.8) |
| 2–3 | 1982 (14.8) | 2692 (20.6) | 1097 (22.3) |
| ≥4 | 289 (2.2) | 616 (4.7) | 310 (6.3) |
| Maize consumption: Mean ± SD, grams/day | 74.0 ± 56.1 | 32.2 ± 35.5 | 25.7 ± 29.0 |
| Healthy Eating Index-2015 | |||
| Q1 | 2976 (22.2) | 2316 (17.7) | 983 (20.0) |
| Q2 | 3009 (22.5) | 2343 (17.9) | 924 (18.8) |
| Q3 | 2844 (21.3) | 2458 (18.8) | 973 (19.8) |
| Q4 | 2512 (18.8) | 2788 (21.3) | 976 (19.9) |
| Q5 | 2041 (15.3) | 3176 (24.3) | 1058 (21.5) |
| Neighborhood socioeconomic status | |||
| Q1 | 4762 (35.6) | 2319 (17.7) | 647 (13.2) |
| Q2 | 4395 (32.8) | 3707 (28.3) | 1359 (27.7) |
| Q3 | 2379 (17.8) | 3297 (25.2) | 1360 (27.7) |
| Q4 | 1269 (9.5) | 2372 (18.1) | 992 (20.2) |
| Q5 | 577 (4.3) | 1386 (10.6) | 556 (11.3) |
| Ethnic enclave | |||
| Q1 | 473 (3.5) | 1093 (8.4) | 416 (8.5) |
| Q2 | 978 (7.3) | 1885 (14.4) | 777 (15.8) |
| Q3 | 2132 (15.9) | 3137 (24.0) | 1381 (28.1) |
| Q4 | 3818 (28.5) | 3756 (28.7) | 1424 (29.0) |
| Q5 | 5981 (44.7) | 3210 (24.5) | 916 (18.6) |
Abbreviations: BMI, body mass index; Q, quintile; SD, standard deviation.
RESULTS
Among 31,377 Mexican American participants in the MEC, 42.6% were first generation, 41.7% were second generation, and 15.7% were third generation. Demographics, lifestyle patterns, and neighborhood attributes differed by generational status. With successive generations in the United States, there was an increase in BMI, current smoking, increased pack-years of cigarette smoking, lower maize consumption, heavy alcohol use, higher coffee intake, and residence in high-nSES areas (Table 1). Greater than 70% of first-generation Mexican Americans tended to reside in neighborhoods that were most ethnically/culturally distinct (Q4–Q5), compared with only approximately 50% of second-generation and third-generation Mexican Americans.
During a mean follow-up of 19.5 years, there were 213 incident cases of HCC. The mean age at diagnosis was slightly younger for third-generation Mexican Americans (71.1 vs. 74.1 years in first-generation Mexican Americans; Table 2). Third-generation Mexican Americans (56.1%) had a higher proportion of localized disease at diagnosis compared with first-generation (45.2%) and second-generation (39.4%) Mexican Americans. First-generation Mexican Americans had an age-adjusted and age-truncated incidence rate of 20.7 HCC cases per 100,000, compared with an increased rate of 27.2 per 100,000 for second-generation and 35.4 per 100,000 for third-generation Mexican Americans.
TABLE 2.
Hepatocellular carcinoma incidence rates and tumor stage among Mexican American adults by generation status.
| First-generation, n = 73 cases | Second-generation, n = 99 cases | Third-generation, n = 41 cases | |
|---|---|---|---|
| Age at diagnosis: Mean ± SD, years | 74.1 ± 7.1 | 75.5 ± 7.6 | 71.1 ± 8.6 |
| Median follow-up, years | 14.3 | 13.5 | 13.7 |
| Stage at diagnosis: No. (%) | |||
| Localized | 33 (45.2) | 39 (39.4) | 23 (56.1) |
| Advanceda | 27 (37.0) | 43 (43.4) | 13 (31.7) |
| Unknown | 13 (17.8) | 17 (17.2) | 5 (12.2) |
| HCC incidence rates, %b | 20.7 | 27.2 | 35.4 |
Abbreviations: HCC, hepatocellular carcinoma; SD, standard deviation.
Includes regional and distant cancer stages.
Per 100,000 and age-adjusted to the US 2000 standard population.
In age-adjusted and sex-adjusted models, second-generation and third-generation Mexican Americans had a 41% (HR, 1.41; 95% CI, 1.03–1.92) and 76% (HR, 1.76; 95% CI, 1.20–2.58) increased risk of HCC, respectively, compared with first-generation Mexican Americans (Table 3). In the fully adjusted multivariable model, second-generation and third-generation Mexican Americans had a 37% (HR, 1.37; 95% CI, 0.98–1.92) and 66% (HR, 1.66; 95% CI, 1.11–2.49) increased risk of HCC, respectively, compared with first-generation Mexican Americans (Table 3). There was a trend toward increased risk from the first generation to the third generation (p for trend = .012) and a 39.3% change in risk for each generation.
TABLE 3.
Association between generational status and hepatocellular carcinoma incidence in Mexican Americans in the Multiethnic Cohort.
| First-generation, n = 13,382 | Second-generation, n = 13,081 | Third-generation, n = 4914 | p for trenda | Generation change, %b | |
|---|---|---|---|---|---|
| All participants, N = 31,377 | |||||
| No. of cases | 73 | 99 | 41 | ||
| Age-adjusted and sex-adjusted HR (95% CI) | 1.00 (Ref) | 1.41 (1.03–1.92) | 1.76 (1.20–2.58) | .003 | 43.9 |
| Fully adjusted HR (95% CI)c | 1.00 (Ref) | 1.37 (0.98–1.92) | 1.66 (1.11–2.49) | .012 | 39.3 |
| Males, n = 15,669 | |||||
| No. of cases | 49 | 71 | 31 | ||
| Age-adjusted HR (95% CI) | 1.00 (Ref) | 1.58 (1.09–2.29) | 2.11 (1.35–3.31) | .001 | 62.5 |
| Fully adjusted HR (95% CI)d | 1.00 (Ref) | 1.60 (1.05–2.44) | 2.08 (1.29–3.37) | .002 | 62.3 |
| Females, n = 15,708 | |||||
| No. of cases | 24 | 28 | 10 | ||
| Age-adjusted HR (95% CI) | 1.00 (Ref) | 1.06 (0.61–1.85) | 1.12 (0.53–2.33) | .765 | 6.8 |
| Fully adjusted HR (95% CI)d | 1.00 (Ref) | 0.95 (0.53–1.71) | 0.93 (0.44–2.00) | .841 | 4.6 |
Abbreviations: CI, confidence interval; HR, hazard ratio; Ref, reference category.
Generation status was coded as 1, 2, or 2.5 and was included as a continuous variable.
Obtained by (1 − hazard ratio)*100 associated with p for trend.
Multivariable model adjusted for age at cohort entry, sex, body mass index, smoking status, alcohol intake, history of diabetes, daily coffee consumption, neighborhood socioeconomic status, ethnic enclave, and clustering by census block group.
Multivariable model adjusted for age at cohort entry, body mass index, smoking status, alcohol intake, history of diabetes, daily coffee consumption, neighborhood socioeconomic status, ethnic enclave, and clustering by census block group.
Sex-stratified analysis revealed differences by sex, although there was no statistically significant heterogeneity (Table 3). In the fully adjusted model, second-generation and third-generation Mexican American males had a 60% (HR, 1.60; 95% CI, 1.05–2.44) and 108% (HR, 2.08; 95% CI, 1.29–3.37) increased risk of HCC, respectively, compared with first-generation Mexican American males. There was a trend toward increased risk from the first generation to the third generation (p for trend = .002) and a 62.3% change in risk for each generation. For females, second-generation and third-generation Mexican Americans had a 5% (HR, 0.95; 95% CI, 0.53–1.71) and 7% (HR, 0.93; 95% CI: 0.44–2.00) decreased risk of HCC, respectively, compared with first-generation Mexican American females, although these trends were not significant (p for trend = .841).
We did not observe heterogeneity in associations by diabetes status (p for heterogeneity = .734; see Table S1), BMI (p for heterogeneity = .859; Table S2), alcohol intake (p for heterogeneity = .272; Table S3), smoking status (p for heterogeneity = .746; Table S4), nSES (p for heterogeneity = .234; Table S5), or ethnic enclave (p for heterogeneity = .912; Table S6).
DISCUSSION
In a large prospective study of Mexican Americans within the California MEC, we observed that the risk of HCC with each successive generation in the United States after adjusting for risk factors. A previous MEC study demonstrated that birthplace is an important risk factor for HCC among Latinos.4 However, birthplace—particularly for those born in the United States—may be further disaggregated by generational status. Generation is rooted in an assimilation/acculturation model whereby parental birthplace significantly influences a child’s lifestyle and behaviors in the host country.28 Accordingly, by disaggregating generational status, this study demonstrated a differential risk of developing HCC among Mexican American adults.
Another study of Latinos in the Florida Cancer Registry reported similar findings of birthplace influencing HCC incidence. Mexican American men residing in Florida in 1999–2001 had a higher incidence of HCC compared with their counterparts residing in Mexico.29 In contrast, Mexican American women in Florida had lower incidence rates compared with their counterparts in Mexico. Pinheiro and colleagues suggest that this may be attributed to male immigrants being more likely to adopt unfavorable health behaviors compared to females.29 Interestingly, we also observed increased HCC risk with successive generations among Mexican American males, but not females. When we examined the characteristics of HCC risk factors across each generation, second-generation and third-generation Mexican American males had a greater proportion of higher alcohol consumption and current smoking compared with Mexican American females. With the exception of coffee consumption,30 alcohol, smoking, and elevated BMI are risk factors for diseases like chronic liver disease and cirrhosis, which ultimately may lead to HCC.31–34 However, despite adjusting for these factors, we still identified differences in HCC risk across generations. This would suggest that there are additional risk factors influencing HCC risk, and further studies are needed to identify these risk factors.
In addition, we observed that third-generation Mexican Americans had a slightly younger age at HCC diagnosis and a higher proportion of localized tumors, suggesting potentially greater access to health care. This is further supported by our data indicating that a higher proportion of third-generation Mexican Americans tended to live in neighborhoods with higher SES and lower ethnic enclave quintile.
A notable strength of our study is that it is the first to use a prospective design to examine the influence of generational status among Mexican Americans on the risk of HCC. Previous studies that used cancer registry data had limited information on birthplace, particularly for Latino populations,35 and did not consider individual-level HCC risk factors. Here, we detected differences in lifestyle behaviors by each successive generation in the United States and also accounted for individual-level factors. In addition, we used residential participant addresses to collect information on their neighborhoods, including nSES and ethnic enclave. Previous studies show that Hispanic adults residing in low-nSES and either low or high ethnic enclaves have increased HCC risk.5,27 Neigh-borhood attributes influence health,36 so including these variables in our models allowed us to comprehensively adjust for both individual-level and neighborhood-level factors. Another strength was that we considered country of origin (Mexico) in our analysis, making our study population more homogenous. Latino populations are a highly heterogenous group, with varying countries of origins and cultures.37 A recent review of cancer epidemiology among Latinos highlighted the need to disaggregate data by nativity and country of origin to reveal risk factors that may be relevant to certain Latino communities.38 Thus we underscore the importance of replicating our findings with other Latino populations from other countries of origin.
A limitation of our study is that we did not differentiate HCC by its different etiologies. HCC includes various etiologies, such as nonalcoholic fatty liver disease, alcohol liver disease, hepatitis B virus infection, and hepatitis C virus (HCV) infection.39 Similar to other studies in Latinos,40,41 HCV infection and nonalcoholic fatty liver disease are the most common HCC etiologies among Latinos in the MEC.42 US-born Latinos tend to have higher prevalence of HCV infection compared with those who are foreign born.41,43,44 Mexican Americans in the United States had a 1.3% HCV prevalence between 1999 and 2002 using National Health and Nutrition Examination Survey data, and this was similar to Latinos in San Diego from the <zaq;6>Hispanic Community Health Study/Study of Latinos.43,44 In California, Hispanic and Latino residents constituted between 5% and 7% of HCV cases between 2014 and 2018.45 When we linked our analytic sample to Medicare fee-for-service information, the number of cases was too small to perform an analysis stratified by the etiologies.
In conclusion, each successive generation of Mexican Americans living in the United States in the MEC was more likely to uptake unfavorable health behaviors. However, even after adjusting for these factors, there was increased risk of HCC with successive generations. Further studies are needed to identify other potential factors that influence these differences after adjustment for lifestyle and neighborhood information.
Supplementary Material
ACKNOWLEDGMENT
This work was supported by the National Cancer Institute (Grant Numbers U01CA164973, R01CA228589, and R01CA154644). The funders had no role in implementation of this study or presentation of results.
Funding information
National Cancer Institute, Grant/Award Numbers: R01CA154644, R01CA228589, U01CA164973
Footnotes
CONFLICT OF INTEREST STATEMENT
Kali Zhou reports institutional grant support from Gilead Sciences outside the submitted work. The remaining authors disclosed no conflicts of interest.
SUPPORTING INFORMATION
Additional supporting information can be found online in the Supporting Information section at the end of this article.
DATA AVAILABILITY STATEMENT
The data described in the article, the code book, and the analytic code will be made available on request pending application and approval.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data described in the article, the code book, and the analytic code will be made available on request pending application and approval.