ABSTRACT
Introduction
Approximately 12.4% of patients with lung cancer experience depression after cancer diagnosis. Asian, Native Hawaiian, and Pacific Islanders (ANHPIs) constitute a large group with heterogeneity. The aim of this study is to examine the racial differences in depression risk, comparing overall ANHPI and ANHPI ethnic groups to non‐Hispanic White (NHW) patients with lung cancer.
Method
We utilized the Surveillance, Epidemiology and End Results (SEER)‐Medicare and SEER—Consumer Assessment of Healthcare Providers and System (CAHPS) dataset. We included patients with primary lung cancer who were aged 66 and older, diagnosed from 2000 to 2017 with full coverage of Medicare Part A and B. One ANHPI patient with lung cancer was matched to three NHW patients with lung cancer based on sex, diagnosis age, and diagnosis year. We used the Cox proportional hazards model to estimate the differences in depression incidence among ANHPI and NHW patients with lung cancer.
Results
Overall ANHPI, Chinese, Japanese, Filipino, Asian Indian or Pakistani, and other Asian patients with lung cancer had a lower incidence of depression than NHW patients with lung cancer. Korean patients with lung cancer (HR 1.62, 95% CI 1.05–2.51) had a higher incidence of depression when compared to Chinese patients with lung cancer. ANHPI and NHW males had a lower incidence of depression compared to female lung cancer patients.
Conclusion
Korean patients with lung cancer may have a higher incidence of depression than Chinese comparisons. More research to investigate the heterogeneity and underdiagnosis of depression risk among older ANHPI groups is needed.
Keywords: Asian, depression, heterogeneity, lung cancer patients, native Hawaiian and Pacific islander, racial difference, risk factors, subgroups
1. Introduction
Lung cancer is the most common cause of cancer death in the U.S. It is also the second most common site of incident cancer cases in the U.S. [1]. In 2024, the estimated number of new lung cancer cases was 234,580 in the U.S. [1]. Because of advancement in screening, early diagnosis, and treatment, the decline in lung cancer mortality has been greater than the decline in lung cancer incidence, resulting in a 1.4% absolute increase in 2‐year relative survival annually [2]. At the beginning of 2022, there were 654,620 individuals diagnosed with lung cancer in the U.S. [3].
The prevalence of depression in the U.S. ranges from 8.0% to 14.2% among those aged 65 years and older in the general population [4, 5, 6, 7]. A previous study reported that 12.4% of lung cancer patients experience clinically manifested depression [8]. Because of the impact on life quality, cancer therapies and the mental stress associated with a relatively lower survival rate for lung cancer, the depression risk is higher after a diagnosis of lung cancer compared to before diagnosis [9, 10]. Although non‐Hispanic Asian individuals have a relatively lower prevalence of depression than other racial and ethnic groups [4, 5, 6], some studies conducted in Asian countries have reported that, among multiple cancer types, depression prevalence is highest in lung cancer patients [11, 12].
Furthermore, the incidence of depression diagnoses among Asian, Native Hawaiian, and Pacific Islander (ANHPI) patients with lung cancer remains unknown. The ANHPI population is a large group with substantial heterogeneity [13]. The burden, risk factors, and outcomes of cancer vary greatly across ANHPI ethnic groups [13]. Clinical and demographic characteristics are also heterogenous among lung cancer patients within ANHPI ethnic groups [14]. Furthermore, underdiagnosis of depression may exist among ANHPI groups because of culture and language barriers, leading to stigma and lack of proper diagnostic tools for depression for ANHPI groups [15]. ANHPI patients may also experience worse access to health care than NHW patients [16]. The primary aim of this study was to examine the racial differences in depression risk, as well as other risk factors for depression, comparing overall ANHPI patients with lung cancer and ANHPI ethnic groups to NHW patients with lung cancer to identify potential disparities in depression incidence.
2. Methods
2.1. Study Population
We utilized the Surveillance, Epidemiology and End Results (SEER)‐Medicare dataset. SEER provides data on clinical and demographic characteristics, as well as outcome information for cancer patients from cancer registries in the U.S., covering 48% of the population in the U.S. Medicare provides enrollment data and healthcare service claims for beneficiaries. SEER‐Medicare is a linked dataset combining these two resources for Medicare beneficiaries with cancer [17].
The selection criteria for the eligible study population were stated in our prior study [18, 19]. Specifically, we originally identified 1,192,518 patients with lung cancer (with SEER code 22030) from the SEER‐Medicare database. We included patients with only first primary lung cancer who were diagnosed between 2000 and 2017, as 1999 is the earliest year for which data are available. We also included NHW and ANHPI patients with lung cancer who were ≥ 66 years, since most Medicare beneficiaries are aged ≥ 65, and we need at least 1 year of baseline comorbidity data. In addition, we excluded patients with in situ or missing stage, as well as those with non‐carcinoma histology (Histology_ICD_O_3 = 8580–9999) or metastasis (Histology_ICD_O_3 = 8005, 8095, 8124, 8130, 8146, 8160, 8170, 8231, 8247, 8263, 8312, 8340–1, 8350, 8370, 8441, 8460, 8500, 8501, 8510, 8524, 8530, 8551). We also excluded patients diagnosed solely through autopsy or death certificate, as they lacked detailed clinical information. Additionally, we excluded lung cancer patients from Idaho, Massachusetts, and New York, since clinical characteristics (e.g., histology) and treatment information were not consistently collected in these registries in the study period.
We further excluded patients with lung cancer who lacked full coverage of Medicare Part A and B after diagnosis and those with any HMO enrollments, to ensure complete claims data. Individuals with less than 1 year of Medicare coverage were also excluded. To establish temporality, we only included patients with ≥ 1 year of follow‐up after diagnosis. Follow‐up time was the period from lung cancer diagnosis to depression diagnosis, the end of the study period, or death, whichever came first. Each ANHPI patient with lung cancer was matched to three NHW patients with lung cancer on sex, age at diagnosis (±1 year), and calendar year of diagnosis (±1 year).
To compare self‐reported depression with clinically diagnosed depression, we used the SEER‐Consumer Assessment of Healthcare Providers and Systems (CAHPS) linked dataset. Medicare CAHPS surveys were designed to assess beneficiaries' healthcare experiences. We selected ANHPI and NHW patients with lung cancer as well as non‐cancer Medicare beneficiaries from SEER‐CAHPS. The inclusion criteria for lung cancer characteristics were consistent with SEER‐Medicare. In SEER‐CAHPS, participants self‐reported their mental health status by selecting from five categories: “Excellent; Very Good; Good; Fair; Poor.” We used the information of the self‐reported mental health as a sensitivity analysis to compare mental health status between NHW and ANHPI patients with lung cancer.
2.2. Outcome and Covariates
For the primary outcome, we identified incident depression from Medicare Provider Analysis and Review (MedPAR), Carrier Claims (NCH), and Outpatient Claims using ICD‐9 and ICD‐10 codes from the 27 Chronic Conditions Data Warehouse (CCW) Chronic Conditions [20]. Individuals with a prior depression diagnosis before lung cancer diagnosis were excluded.
The covariates of interest included demographic characteristics such as sex, age at diagnosis, registry area, urbanization (urban, rural), education, and income. Clinical characteristics included vital status, baseline Charlson comorbidity index (CCI), lung cancer sequence number, histology, laterality, stage, and cancer therapies. We also included ICD codes for obesity and tobacco use disorders. Urban areas were counties within metropolitan areas (Rural–Urban Continuum code 0–3), while rural areas were defined as non‐metropolitan areas (Rural–Urban Continuum code 4–9). Education and income levels were assigned at the population level based on the closest census tract at the time of lung cancer diagnosis. Education level was defined as the percentage of individuals with a college or higher, and the income level was defined as the median household income. Baseline CCI was determined using diagnostic codes from MedPAR, NCH, and outpatient claims within 1 year before lung cancer diagnosis [21].
2.3. Statistical Analysis
To compare the depression incidence among overall ANHPI patients with lung cancer and ANHPI ethnic groups to NHW patients with lung cancer, we used the Cox proportional hazards model, with the NHW patients with lung cancer as a reference group. We presented hazard ratios (HRs) and 95% confidence intervals (95% CIs) to estimate the incidence of depression. In the model, we retained the matching pair stratification of matching factors (diagnosis age, diagnosis year, sex) and additionally adjusted for the registry area. We further estimated the risk of depression among ANHPI ethnic groups, compared to Chinese patients with lung cancer as the largest ANHPI ethnic group with lung cancer to investigate differences in the ANHPI ethnic groups. We also used the Cox hazards model with diagnosis age, diagnosis year, sex, and registry area adjusted among ANHPI subgroups.
We conducted stratified analyses by sex and follow‐up years (1–5 years and > 5 years) using the same Cox model for ANHPI vs. NHW patients with lung cancer and ANHPI ethnic groups vs. Chinese patients with lung cancer. To estimate the association between baseline characteristics and depression, we used the Cox hazards model to investigate risk factors for depression, respectively for NHW and ANHPI patients with lung cancer, with adjustment for potential confounders. We included a time‐dependent covariate in the Cox regression model to test the proportionality assumption. If it was not met, we used a flexible parametric survival model [22].
To account for competing risks, we applied the Fine‐Gary competing risk model, treating death as a competing event for depression incidence after lung cancer diagnosis. We further adjusted for multiple covariates in three models of Cox proportional hazards models. To investigate potential selection bias related to Medicare Part A and B utilization, the number of claims was compared among Asian, NHPI (Native Hawaiian and Pacific Islander) and NHW patients with lung cancer.
For the SEER‐CAHPS analysis, we compared self‐reported mental health status between the general Medicare population and lung cancer patients. We examined the distributions of mental health status categories among SEER lung cancer patients and non‐cancer Medicare beneficiaries, stratified by ANHPI and NHW groups. We then used a logistic regression model to investigate the odds ratios (ORs) for self‐reported mental health status (very good vs. excellent, good vs. excellent, fair vs. excellent, poor vs. excellent), comparing ANHPI to NHW individuals, while adjusting for registry area. We conducted a stratified analysis by Medicare plan type.
We obtained Institutional Review Board (IRB) approval from the University of Utah. We used SAS 9.4 (SAS Institute Inc., Cary, NC) for data analysis except for flexible parametric survival analysis (STATA 17).
3. Results
We identified 3920 ANHPI patients with lung cancer and matched 11,760 NHW patients with lung cancer (Table S1). We included 1042 (26.58%) Chinese, 670 (17.09%) Japanese, 652 (16.63%) Filipino, 433 (11.05%) Vietnamese, 356 (9.08%) Korean, 188 (4.80%) Hawaiian, 143 (3.65%) Indian or Pakistani, 67 (1.71%) Pacific Islander, 54 (1.38%) Southeast Asian, and 315 (8.04%) all other Asian patients with lung cancer. The eligibility criteria are in Figure 1. The clinical and demographic characteristics of ANHPI ethnic groups and NHW patients with lung cancer are in Table 1. Compared to NHW patients with lung cancer, all ANHPI ethnic groups with lung cancer, except for NHPI patients with lung cancer, had lower CCI, a higher proportion were alive, and were living in the West or urban areas. South and East Asian patients with lung cancer had relatively higher census‐tract level education and income levels than NHW patients with lung cancer. All ANHPI ethnic groups with lung cancer had a lower proportion of tobacco use disorders than NHW patients with lung cancer, but the prevalence of these disorders was relatively higher in NHPI patients with lung cancer compared to the other ANHPI ethnic groups. All ANHPI ethnic groups had a lower proportion of obesity than NHW patients with lung cancer, except for NHPI patients with lung cancer.
FIGURE 1.
Eligibility criteria for the patients of ANHPI and NHW with lung cancer in the SEER Medicare data.
TABLE 1.
Demographic and clinical characteristics of the ANHPI and NHW patients with lung cancer in SEER Medicare.
| East Asian lung cancer survivors (n = 2068) | Southeast Asian lung cancer survivors (n = 1139) | South Asian lung cancer survivors (n = 143) | NHPI lung cancer survivors (n = 255) | NHW lung cancer survivors (n = 11,760) | |
|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | n (%) | n (%) | |
| Sex | |||||
| Male | 1020 (49.32) | 602 (52.85) | 83 (58.04) | 132 (51.76) | 5919 (50.33) |
| Female | 1048 (50.68) | 537 (47.15) | 60 (41.96) | 123 (48.24) | 5841 (49.67) |
| Age at diagnosis, year | |||||
| 66–70 | 409 (19.78) | 283 (24.85) | > 39 (> 27.27) | > 77 (> 30.20) | 2637 (22.42) |
| 71–75 | 557 (26.93) | 342 (30.03) | 41 (28.67) | 77 (30.20) | 3309 (28.14) |
| 76–80 | 529 (25.58) | 288 (25.29) | 37 (25.87) | 65 (25.49) | 3027 (25.74) |
| 81–85 | 381 (18.42) | 156 (13.70) | 15 (10.49) | 25 (9.80) | 1854 (15.77) |
| 86+ | 192 (9.28) | 70 (6.15) | < 11 (< 7.69) e | < 11 (< 4.31) e | 933 (7.93) |
| Charlson Comorbidity Index (CCI) at baseline | |||||
| 0 | 767 (37.09) | 388 (34.06) | 54 (37.76) | 93 (36.47) | 3676 (31.26) |
| 1 | 671 (32.45) | 344 (30.20) | 39 (27.27) | 77 (30.20) | 3674 (31.24) |
| 2+ | 630 (30.46) | 407 (35.73) | 50 (34.97) | 85 (33.33) | 4410 (37.50) |
| Vital status | |||||
| Alive | 443 (21.42) | 276 (24.23) | 50 (34.97) | 40 (15.69) | 2453 (20.86) |
| Dead | 1625 (78.58) | 863 (75.77) | 93 (65.03) | 215 (84.31) | 9307 (79.14) |
| Registry area | |||||
| West | 1888 (91.30) | 1042 (91.48) | 63 (44.06) | > 222 (> 87.06) | 3991 (33.94) |
| Northeast | 127 (6.14) | 51 (4.48) | 52 (36.36) | < 11 (< 4.31) e | 2679 (22.78) |
| Midwest | 17 (0.82) | 16 (1.40) | 11 (7.69) | < 11 (< 4.31) e | 1619 (13.77) |
| South | 36 (1.74) | 30 (2.63) | 17 (11.89) | < 11 (< 4.31) e | 3471 (29.52) |
| Rural residence | |||||
| Urban a | > 1985 (> 95.99) | > 1090 (> 95.70) | > 121 (> 84.62) | > 183 (> 71.76) | > 9451 (> 80.29) |
| Rural | 72 (3.48) | 38 (3.34) | < 11 (7.69) e | 61 (23.92) | 2307 (19.62) |
| Unknown | < 11 (< 0.53) e | < 11 (0.97) e | < 11 (7.69) e | < 11 (< 4.31) e | < 11 (< 0.09) e |
| Education: proportion above college b (census tract) | |||||
| 0%–40% | 284 (13.73) | 232 (20.37) | < 11 (7.69) e | 37 (14.51) | 2388 (20.31) |
| < 40%–60% | 628 (30.37) | > 455 (> 39.95) | 42 (29.37) | > 118 (> 46.27) | 4208 (35.78) |
| < 60%–80% | > 799 (> 38.64) | 352 (30.90) | > 52 (> 36.36) | 78 (30.59) | 3740 (31.80) |
| < 80%–100% | 346 (16.73) | 89 (7.81) | 27 (18.88) | 11 (4.31) | 1413 (12.02) |
| Missing | < 11 (< 0.53) e | < 11 (0.97) e | < 11 (7.69) e | < 11 (< 4.31) e | 11 (0.09) |
| Income (median income in census tract) | |||||
| ≤ 40,000 | 476 (23.02) | 229 (20.11) | 13 (9.09) | 53 (20.78) | 3273 (27.83) |
| 40,000–60,000 | > 559 (> 27.03) | > 389 (> 34.15) | 41 (28.67) | > 83 (> 32.55) | 3996 (33.98) |
| 60,000–80,000 | 510 (24.66) | 293 (25.72) | 31 (21.68) | 76 (29.80) | 2344 (19.93) |
| > 80,000 | 512 (24.76) | 217 (19.05) | > 47 (> 32.87) | 32 (12.55) | 2135 (18.15) |
| Missing | < 11 (< 0.53) e | < 11 (0.97) e | < 11 (7.69) e | < 11 (< 4.31) e | 12 (0.10) |
| Tobacco use disorders | |||||
| Yes | 277 (13.39) | 178 (15.63) | 28 (19.58) | 80 (31.37) | 3963 (33.70) |
| No | 1791 (86.61) | 961 (84.37) | 115 (80.42) | 175 (68.63) | 7797 (66.30) |
| Obesity | |||||
| Yes | 70 (3.38) | 77 (6.76) | < 11 (7.69) e | 39 (15.29) | 1555 (13.22) |
| No | 1998 (96.62) | 1062 (93.24) | > 132 (> 92.31) | 216 (84.17) | 10,205 (86.78) |
| Sequence number | |||||
| One primary only | 1846 (89.26) | 1039 (91.22) | 125 (87.41) | 216 (84.71) | 10,121 (86.06) |
| First of many primaries | 222 (10.74) | 100 (8.78) | 18 (12.59) | 39 (15.29) | 1639 (13.94) |
| Histology | |||||
| SCLC‐Small cell | 114 (5.51) | 52 (4.57) | < 11 (7.69) e | 20 (7.84) | 964 (8.20) |
| NSCLC‐Adenocarcinoma | 1220 (58.99) | 745 (65.41) | > 76 (> 53.15) | > 113 (> 44.31) | 5111 (43.46) |
| NSCLC‐Squamous cell | 359 (17.36) | 154 (13.52) | 22 (15.38) | 68 (26.67) | 3166 (26.92) |
| NSCLC‐Large cell carcinoma | 48 (2.32) | 16 (1.40) | < 11 (7.69) e | < 11 (< 4.31) e | 251 (2.13) |
| Other NSCLC | 228 (11.03) | 114 (10.01) | 12 (8.39) | 31 (12.16) | 1506 (12.81) |
| Unspecific lung cancer | 99 (4.79) | 58 (5.09) | < 11 (7.69) e | 12 (4.17) | 762 (6.48) |
| Laterality | |||||
| Right: origin of primary | 1168 (56.48) | 647 (56.80) | > 64 (> 44.76) | > 147 (> 57.65) | 6744 (57.35) |
| Left: origin of primary | 844 (40.81) | 463 (40.65) | 68 (47.55) | 97 (38.04) | 4756 (40.44) |
| Others c | 56 (2.71) | 29 (2.55) | < 11 (7.69) e | < 11 (< 4.31) e | 260 (2.21) |
| Stage | |||||
| Localized | 611 (29.55) | 337 (29.59) | 49 (34.27) | 74 (29.02) | 4432 (37.69) |
| Regional | 606 (29.30) | 302 (26.51) | 43 (30.07) | 95 (37.25) | 3866 (32.87) |
| Distant | 851 (41.15) | 500 (43.90) | 51 (35.66) | 86 (33.73) | 3462 (29.44) |
| Radiation | |||||
| Yes | 693 (33.51) | 383 (33.63) | 54 (37.76) | 111 (43.53) | 4650 (39.54) |
| No | 1358 (65.67) | > 745 (> 65.41) | > 78 (> 54.55) | > 133 (> 52.16) | 6918 (58.83) |
| Unknown | 17 (0.82) | < 11 (0.97) e | < 11 (7.69) e | < 11 (< 4.31) e | 192 (1.63) |
| Chemotherapy | |||||
| Yes | 950 (45.94) | 517 (45.39) | 56 (39.16) | 115 (45.10) | 4599 (39.11) |
| No/unknown d | 1118 (54.06) | 622 (54.61) | 87 (60.84) | 140 (54.90) | 7161 (60.89) |
| Surgery | |||||
| Yes | 767 (37.09) | 347 (30.47) | 60 (41.96) | 91 (35.69) | 4654 (39.57) |
| No | > 1290 (> 62.38) | > 781 (> 68.57) | > 72 (> 50.35) | > 153 (> 60.00) | 7045 (59.91) |
| Unknown | < 11 (< 0.53) e | < 11 (0.97) e | < 11 (7.69) e | < 11 (< 4.31) e | 61 (0.52) |
Abbreviations: NHPI, Native Hawaiian and Pacific Islander; NHW, Non‐Hispanic White.
Urban is defined as cities of metropolitan areas (code 0–3 of Rural–Urban Continuum/Beale code); Rural is defined as cities of non‐metropolitan areas (code 4–9 of Rural–Urban Continuum/Beale code).
Including some college and at least 4 years of college.
Others includes: not a paired site; only one side involved, right or left origin unspecified; bilateral involvement, lateral origin unknown; stated to be single primary; paired site.
The original dataset combined No and Unknown together.
Counts < 11 are not shown, Centers for Medicare & Medicaid Services (CMS) Cell Suppression Policy.
For clinical factors, there were fewer squamous cell carcinomas and small cell, but more adenocarcinoma cases in the ANHPI ethnic group with lung cancer. South Asian patients had relatively more left‐side lung cancer compared to all other patients with lung cancer. All ANHPI ethnic groups with lung cancer had higher proportions of being diagnosed at a distant stage. Compared to NHW patients with lung cancer, Southeast and East Asian patients with lung cancer had a lower proportion of radiation therapy, and Southeast Asian patients with lung cancer were also less likely to receive surgery. However, East Asian, Southeast Asian, and NHPI patients with lung cancer had a higher proportion of chemotherapy than NHW patients with lung cancer.
The HRs with 95% CIs for depression, for overall ANHPI and ANHPI ethnic groups comparing to NHW patients with lung cancer, are shown in Table 2. Overall ANHPI (HR 0.60, 95% CI 0.50–0.73), Chinese (HR 0.56, 95% CI 0.39–0.79), Japanese (HR 0.57, 95% CI 0.38–0.87), Filipino (HR 0.61, 95% CI 0.39–0.96), Asian Indian or Pakistani (HR 0.33, 95% CI 0.12–0.87) patients with lung cancer had a lower incidence of depression compared to NHW patients with lung cancer. The HRs and 95% CIs of depression, comparing ANHPI ethnic groups to Chinese patients with lung cancer, are also shown in Table 2. Korean patients with lung cancer (HR 1.62, 95% CI 1.05–2.51) had a higher incidence of depression than Chinese patients with lung cancer.
TABLE 2.
Hazard ratio (HR) and 95% confidence intervals (CIs) of depression, ANHPI/ANHPI ethnic groups versus NHW lung cancer patients a , ANHPI ethnic groups versus Chinese lung cancer patients b .
| Incidence density (/1000 years) | Hazard ratio (95% CIs) | Hazard ratio (95% CIs) | |
|---|---|---|---|
| NHW | 34.2 | 1 (reference) | |
| ANHPI | 20.63 | 0.60 (0.50, 0.73) | |
| Chinese | 18.21 | 0.56 (0.39, 0.79) | 1 (reference) |
| Japanese | 22.00 | 0.57 (0.38, 0.87) | 1.13 (0.79, 1.63) |
| Filipino | 19.93 | 0.61 (0.39, 0.96) | 1.14 (0.77, 1.68) |
| Hawaiian | 19.42 | 0.71 (0.34, 1.49) | 1.17 (0.62, 2.22) |
| Korean | 27.08 | 0.81 (0.49, 1.35) | 1.62 (1,05, 2.51) |
| Vietnamese | 21.29 | 0.80 (0.49, 1.31) | 1.18 (0.77, 1.83) |
| Asian Indian or Pakistani | 17.95 | 0.33 (0.12, 0.87) | 0.84 (0.41, 1.73) |
| Other Southeast Asian c | 35.47 | 1.32 (0.35, 5.05) | 2.07 (0.83, 5.19) |
| Pacific Islander | 20.63 | 0.55 (0.15, 2.01) | 1.11 (0.44, 2.75) |
| Other Asian d | 19.61 | 0.40 (0.22, 0.73) | 0.98 (0.60, 1.58) |
Abbreviations: ANHPI: Asian, Native Hawaiian and Pacific Islander; NHW: Non‐Hispanic White.
The model adjusted for registry area and matched pair.
The model adjusted for registry area, diagnosis age, diagnosis year, and sex.
Other Southeast Asian: including Laotian, Hmong, Kampuchean and Thai.
Other Asian: including Asian, NOS and Oriental, NOS.
We further stratified the HRs and 95% CIs of depression by sex in Table 3. Overall ANHPI, Korean, and Chinese patients with lung cancer had a lower incidence of depression among men, and overall ANHPI, Japanese, and Filipino patients with lung cancer had a lower incidence of depression among women, compared to NHW patients with lung cancer. Among women, compared to Chinese patients with lung cancer, Southeast and Korean Asian patients with lung cancer had a higher incidence of depression. We also stratified the HRs and 95% CIs of depression by follow‐up years in Table S2. The results for 1–5 follow‐up years were similar to the results of Table 2, but we observed that, compared to Chinese patients with lung cancer, Hawaiian patients with ≥ 5‐year follow‐up time had a higher incidence of depression.
TABLE 3.
Hazard ratio (HR) and 95% confidence intervals (CIs) of depression, ANHPI/ANHPI ethnic groups versus NHW lung cancer patients a , ANHPI ethnic groups versus Chinese lung cancer patients b , stratified by sex.
| Case (N)/total (N) | Hazard ratio (95% CIs) | Case (N)/total (N) | Hazard ratio (95% CIs) | |
|---|---|---|---|---|
| Male | Female | |||
| NHW a | 537/5132 | 1 (reference) | 669/4500 | 1 (reference) |
| Overall APIs | 111/1847 | 0.56 (0.41, 0.76) | 164/1736 | 0.62 (0.49, 0.80) |
| Chinese | 28/509 | 0.37 (0.20, 0.67) | 38/461 | 0.72 (0.46, 1.10) |
| Japanese | 14/282 | 0.64 (0.32, 1.30) | 40/340 | 0.54 (0.33, 0.90) |
| Filipino | 23/309 | 0.77 (0.42, 1.42) | 19/292 | 0.48 (0.25, 0.93) |
| Hawaiian | */89 | 1.25 (0.44, 3.51) | */78 | 0.41 (0.13, 1.25) |
| Korean | */186 | 0.34 (0.14, 0.84) | 21/133 | 1.57 (0.79, 3.10) |
| Vietnamese | 17/216 | 1.16 (0.58, 2.32) | 13/165 | 0.56 (0.28, 1.14) |
| Indian or Pakistani | */73 | 0.26 (0.06, 1.18) | */53 | 0.39 (0.11, 1.41) |
| Other Southeast Asian c | */26 | — | */19 | 2.30 (0.50, 10.51) |
| Pacific Islander | */32 | — | */31 | 1.14 (0.26, 5.03) |
| Other Asian d | 7/125 | 0.54 (0.19, 1.55) | 16/164 | 0.35 (0.17, 0.73) |
| Chinese b | 1 (reference) | 1 (reference) | ||
| Japanese | 0.90 (0.47, 1.72) | 1.20 (0.76, 1.88) | ||
| Filipino | 1.66 (0.95, 2.89) | 0.81 (0.47, 1.41) | ||
| Hawaiian | 1.63 (0.71, 3.76) | 0.77 (0.27, 2.17) | ||
| Korean | 0.86 (0.40, 1.85) | 2.49 (1.46, 4.27) | ||
| Vietnamese | 1.54 (0.83, 2.85) | 0.88 (0.47, 1.66) | ||
| Indian or Pakistani | 0.78 (0.25, 2.40) | 0.86 (0.33, 2.25) | ||
| Other Southeast Asian c | 0.72 (0.10, 5.43) | 3.69 (1.30, 10.49) | ||
| Pacific Islander | 0.69 (0.09, 5.15) | 1.29 (0.46, 3.63) | ||
| Other Asian d | 0.79 (0.34, 1.83) | 1.03 (0.57, 1.87) | ||
Abbreviations: ANHPI, Asian, Native Hawaiian and Pacific Islander; NHW, Non‐Hispanic White.
The model adjusts for registry area and matched pair.
The model adjusts for registry area, diagnosis age, and diagnosis year.
Other Southeast Asian: including Laotian, Hmong, Kampuchean and Thai.
Other Asian: including Asian, NOS and Oriental, NOS.
Counts < 11 are not shown, Centers for Medicare & Medicaid Services (CMS) Cell Suppression Policy.
To consider the competing risk of death, we conducted a Fine‐Gray model in Table S3. The results were similar to the Cox hazards model except that Korean and Vietnamese patients with lung cancer had a relatively lower incidence of depression than NHW patients with lung cancer, and Japanese patients with lung cancer had a relatively higher incidence of depression than Chinese patients with lung cancer.
The HRs with 95% CIs for potential clinical and demographic risk factors of depression among ANHPI and NHW patients with lung cancer are shown in Table 4. Both ANHPI and NHW male patients with lung cancer had a lower incidence of depression compared to corresponding female patients with lung cancer. Lung cancer diagnosis in patients aged in their 70s was related to a higher incidence of depression in ANHPI patients with lung cancer compared to the 66–70‐year age group. Higher baseline CCI, registry area in the South, and having a tobacco use disorder were related to a higher incidence of depression in both ANHPI and NHW patients with lung cancer. We did not observe any association between urban residence, education level, income level, or obesity and the incidence of depression. For clinical characteristics, we observed that small cell lung cancer was associated with a higher incidence of depression in NHW patients with lung cancer compared to non‐small cell lung cancer. Diagnosis at a distant stage was also related to a higher incidence of depression among ANHPI and NHW patients with lung cancer. Radiation therapy and chemotherapy were associated with a higher incidence of depression in NHW patients with lung cancer, while surgery was related to a lower incidence of depression in both ANHPI and NHW patients with lung cancer.
TABLE 4.
Hazard ratio (HR) and 95% confidence intervals (CIs) for potential risk factors for depression among ANHPI and NHW patients with lung cancer.
| ANHPIs | NHWs | |||
|---|---|---|---|---|
| Depression (N)/total (N) | Hazard ratio (95% CIs) | Depression (N)/total (N) | Hazard ratio (95% CIs) | |
| Sex | ||||
| Female | 164/1736 | 1 (reference) | 669/4500 | 1 (reference) |
| Male | 111/1847 | 0.73 (0.58, 0.94) | 537/5132 | 0.83 (0.74, 0.93) |
| Age at diagnosis, year a | ||||
| 66–70 | 55/826 | 1 (reference) | 320/2145 | 1 (reference) |
| 71–75 | 90/1006 | 1.51 (1.08, 2.12) j | 357/2735 | 0.91 (0.78, 1.06) |
| 76–80 | 77/908 | 1.48 (1.04, 2.12) j | 312/2466 | 1.02 (0.87, 1.19) |
| 81–85 | 39/572 | 1.50 (0.99, 2.29) j | 156/1523 | 0.95 (0.78, 1.15) |
| 86+ | 14/271 | 1.47 (0.80, 2.70) j | 61/763 | 0.79 (0.60, 1.05) |
| Charlson Comorbidity Index (CCI) at baseline b | ||||
| 0 | 92/1332 | 1 (reference) | 355/3206 | 1 (reference) |
| 1 | 102/1137 | 1.45 (1.09, 1.92) | 406/3011 | 1.36 (1.18, 1.58) |
| 2+ | 81/1114 | 1.35 (0.99, 1.84) | 445/3415 | 1.57 (1.36, 1.82) |
| Registry area c | ||||
| West | > 228/3192 | 1 (reference) | 393/3251 | 1 (reference) |
| Northeast | 20/231 | 1.28 (0.80, 2.05) | 303/2225 | 1.12 (0.95, 1.32) |
| Midwest | < 11/52 i | 1.55 (0.69, 3.49) | 149/1325 | 1.11 (0.91, 1.34) |
| South | 15/108 | 1.84 (1.08, 3.14) | 361/2831 | 1.17 (1.00, 1.37) |
| Tobacco use disorder d | ||||
| No | 223/3051 | 1 (reference) | 798/6619 | 1 (reference) |
| Yes | 52/532 | 1.53 (1.11, 2.10) | 408/3013 | 1.21 (1.06, 1.37) |
| Obesity e | ||||
| No | 257/3391 | 1 (reference) | 1045/8480 | 1 (reference) |
| Yes | 18/192 | 1.27 (0.77, 2.07) | 161/1152 | 1.11 (0.93, 1.32) |
| Histology f | ||||
| NSCLC | > 248/3211 | 1 (reference) | 1068/8247 | 1 (reference) |
| SCLC | < 11/188 i | 1.16 (0.59, 2.29) | 75/785 | 1.32 (1.04, 1.67) |
| Unspecific | 16/184 | 1.47 (0.88, 2.45) | 63/600 | 1.17 (0.90, 1.51) |
| Stage g | ||||
| Localized | 93/1059 | 1 (reference) | 570/3570 | 1 (reference) |
| Regional | 88/1040 | 1.28 (0.95, 1.72) | 406/3134 | 1.11 (0.98, 1.27) |
| Distant | 94/1484 | 1.90 (1.40, 2.59) | 230/2928 | 1.24 (1.06, 1.46) |
| Radiation therapy h | ||||
| No | > 183/2331 | 1 (reference) | 764/5692 | 1 (reference) |
| Yes | 81/1219 | 1.19 (0.90, 1.56) | 422/3782 | 1.28 (1.13, 1.46) |
| Unknown | < 11/33 i | 1.69 (0.53, 5.35) | 20/158 | 1.18 (0.76, 1.85) |
| Chemotherapy h | ||||
| No/unknown | 164/1967 | 1 (reference) | 805/5774 | 1 (reference) |
| Yes | 111/1616 | 1.12 (0.84, 1.50) | 401/3858 | 1.25 (1.07, 1.44) j |
| Surgery h | ||||
| No | > 145/> 2301 | 1 (reference) | 542/5764 | 1 (reference) |
| Yes | 119/1271 | 0.53 (0.39, 0.74) j | > 653/3820 | 0.76 (0.66, 0.88) j |
| Unknown | < 11/< 11 i | 1.52 (0.20, 11.48) j | < 11/48 i | 0.69 (0.22, 2.15) j |
Note: We investigated the following variables but did not identify any associations: rural residence, education, income, alcohol, and laterality.
Abbreviations: ANHPI, Asian, Native Hawaiian and Pacific Islander; NHW, Non‐Hispanic White; NSCLC, Non‐small cell lung cancer; SCLC, Small cell lung cancer.
Adjusted for sex, diagnosis year, CCI, urbanization, registry area, income, education, histology, and stage of lung cancer.
Adjusted for sex, registry area, urbanization, income, education, diagnosis age, diagnosis year, and tobacco use.
Adjusted for sex, urbanization, income, education, diagnosis age, and diagnosis year.
Adjusted for sex, CCI, registry area, urbanization, income, education, diagnosis age, and diagnosis year.
Adjusted for sex, CCI, registry area, urbanization, income, education, diagnosis age, diagnosis year, tobacco use, and alcohol use.
Adjusted for sex, CCI, registry area, urbanization, income, education, diagnosis age and diagnosis year, tobacco use, alcohol use, and obesity.
Adjusted for sex, CCI, registry area, urbanization, income, education, diagnosis age and diagnosis year, histology, tobacco use, alcohol use, and obesity.
Adjusted for sex, CCI, registry area, urbanization, income, education, diagnosis age and diagnosis year, histology, and stage.
Counts < 11 are not shown, Centers for Medicare & Medicaid Services (CMS) Cell Suppression Policy.
Proportional assumption does not meet, using flexible parameter survival model.
In terms of healthcare utilization, the number of Medicare claims after lung cancer diagnosis was similar between Asian and NHW patients with lung cancer, but NHPI patients with lung cancer had fewer claims (Table S4). When comparing different adjustment models, we observed that overall ANHPI, Chinese, Japanese, and Asian Indian or Pakistani patients with lung cancer had a lower incidence of depression compared to NHW patients with lung cancer in all three adjustment models (Table S5).
To examine self‐reported mental health in SEER‐CAHPS, we observed that both Asian patients with lung cancer and Asian non‐cancer Medicare beneficiaries had a lower proportion reporting “Excellent” mental health status, and HNPI non‐cancer Medicare beneficiaries had a higher proportion of reporting “Poor” mental health status (Table S6). Further in SEER‐CAHPS, ANHPI individuals had higher odds of having worse mental health status than NHW individuals among non‐cancer individuals, and this remained true regardless of the Medicare plan type (Table S7).
4. Discussion
We observed that, compared to NHW patients with lung cancer, there was a lower incidence of depression among ANHPI patients with lung cancer and specific ANHPI ethnic groups (Chinese, Japanese, Filipino, Indian, or Pakistani). Within the ANHPI ethnic groups, Korean patients with lung cancer had a higher incidence of depression than Chinese patients with lung cancer.
In terms of depression in ANHPI individuals without cancer, a review reported lower depression prevalence than other racial/ethnic groups [23]. A study on Chinese Americans reported a decreased prevalence of long‐term major depressive disorder in the Chinese American Psychiatric Epidemiological Study [24]. Asians had the lowest rate of lifetime major depressive episode compared to other racial/ethnic groups, and Filipinos were the group with the lowest rate of MDE [25]. Another study on 16 Asian American groups in New York City reported that Asian Indians had the lowest risk of depression [26]. Our results on Asian patients with lung cancer were similar to the results of these studies among Asian individuals without cancer. A previous meta‐analysis observed that among Korean Americans, the risk of depression was twice as high as that for Chinese Americans [27], which was also similar to our results. However, it was also reported in this meta‐analysis that Filipino Americans had twice the risk of depression compared to Chinese Americans, which was different from our results [27]. The increased risk of depression among older Korean patients with lung cancer could be associated with social stress, marital and living status, comorbidities, education level, cognitive impairment, and depression awareness [28, 29].
Stigma surrounding mental health issues may be a major issue for Asians in the U.S. A previous cross‐sectional study reported that Asians in the U.S. had greater stigma of mental health issue than White populations, and males had greater stigma than females among Asian Americans [30]. Additionally, a previous national online survey also reported that Asian Americans had a higher level of depression stigma than European Americans because of greater social distance, blame, anger, and fear, and were less likely to hire individuals with depression [31]. Other previous studies also reported that NHPI groups and specific Asian subgroups in the U.S. who experience depression stigma change their health care seeking behavior [32, 33]. Older age, male gender, years in the U.S., English language levels and acculturation were related to depression stigma among Asians in the U.S. [33]. Other factors associated with underdiagnosis among ANHPI population may also exist, including immigration status, language barriers acculturation, leading to underestimation of depression risk among ANHPI population [34]. The stigma and the barrier of seeking for healthcare among ANHPI population could partially explain the differential results between Medicare and CAHPS. Other reason could be that ANHPI patients with cancer were more likely to select neutral options (e.g., Good or Fair) because of cultural tendencies.
For previous studies among patients of lung cancer also focusing on depression, a study using the SEER‐Medicare Health Outcomes Survey (MHOS) data reported that compared to other racial or ethnic groups, Asian or Pacific Islander patients with lung cancer had a relatively increased mental component summary score pre‐ and post‐diagnosis indicating a better mental health status [35]. Another study based on the SEER‐CAHPS, including 2603 older lung cancer patients, reported that Asian patients with lung cancer had worse experiences in health care service, including quality, efficiency, and getting needed drugs and care, compared to White patients with lung cancer. It was also reported that Asian patients with lung cancer had more barriers to get health care quickly compared to White patients with lung cancer [36]. In our study, we observed that the number of Medicare claims among Asian patients with lung cancer was similar to the claim frequency among NHW patients with lung cancer. In our analysis of SEER‐CAHPS data, we observed a higher proportion of older NHPI patients with lung cancer reporting poor mental health status compared to NHW patients with lung cancer. Geography distance may not explain the barriers to menial health care in ANHPI groups, since ANHPI ethnic groups had a higher proportion residing in urban area than NHW patients with lung cancer in our study, except NHPI patients with lung cancer. Culture or language barriers to healthcare for ANHPI patients with lung cancer can explain why they had higher odds of reporting worse mental health status in a SEER‐CAHPS study but had a lower incidence of depression in our SEER‐Medicare analysis.
In terms of depression risk factors among patients with lung cancer, we observed that females had a higher incidence of depression than males for NHW and ANHPI patients with lung cancer. We also observed that Korean and other Southeast Asian patients with lung cancer had a higher incidence of depression than Chinese patients with lung cancer among females but not among males. Previous studies have also reported that female gender was related to a higher risk of depression among lung cancer patients [9, 37, 38, 39, 40, 41].
For clinical factors, we observed that ANHPI and NHW patients with lung cancer receiving surgical cancer treatment had a lower incidence of depression than those without surgery. A previous study with 278 lung cancer patients with surgical resection reported that the depression prevalence was higher postoperatively than preoperatively in the same group of lung cancer patients. This study reported that thoracotomy and severe pain were associated with depression after resection [42].
We observed some differences between results from the Cox hazards model (cause‐specific hazard) and from the Fine‐Gray model (sub‐distribution hazard) especially for Japanese, Korean, Vietnamese, and Asian Indian and Pakistani patients compared to NHW patients with lung cancer, and for Japanese and Korean patients compared to Chinese patients with lung cancer. The differences between these two models may result from the survival differences for these subgroups compared to the reference group.
There were some limitations in this study. Individuals who were ever enrolled in HMO enrollment were excluded. A previous study reported that cancer patients with HMO enrollment were diagnosed at an earlier stage and younger [43], thus our results may be generalizable only to traditional, fee‐for‐service Medicare beneficiaries. Additionally, we may have been affected by information bias in socioeconomic status, tobacco use, and cancer treatment data. The education and income variables were based on census‐tract levels rather than on an individual level. The information on tobacco use disorders and obesity was from Medicare claims, so there may have been an underestimation of these factors. Additionally, sensitivity for radiation and chemotherapy data may be low [44]. The questionnaire from SEER‐CAHPS is self‐reported, which is a different perspective and method to evaluate mental health status compared to claim‐based depression SEER‐Medicare. Lastly, the ANHPI population is a heterogenous group consisting of different racial/ethnic groups. We had a limited sample size for some ANHPI ethnic groups with lung cancer, such as Pacific Islander, or Indian or Pakistani, which restricted our statistical power to investigate possible associations and resulted in wide CIs. Though we adjusted for registry area, residual confounding may also exist because of the substantial regional clustering among ANHPI ethnic groups. Furthermore, since we use a claim‐based algorithm to identify incident depression among ANHPI groups and NHW patients with lung cancer, there might be an underestimation for the incident depression due to the undiagnosed and untreated incident depression. Meanwhile, differential misclassification may also exist because there might be differential healthcare utilization of Medicare across the subgroups.
5. Conclusion
We observed that there is a lower incidence of depression for ANHPI patients with lung cancer and specific ANHPI ethnic groups (Chinese, Japanese, Filipino, Asian Indian or Pakistani, and other Asian patients with lung cancer) compared to NHW patients with lung cancer. Korean patients with lung cancer had an increased incidence of depression than Chinese patients with lung cancer. We also observed that female patients with lung cancer had a higher incidence of depression than male patients with lung cancer. More research with greater sample sizes of ANHPI ethnic groups among patients with lung cancer is needed to examine the potential racial disparity in depression and related healthcare.
Author Contributions
Yancen Pan: conceptualization (equal), formal analysis (equal), methodology (equal), software (equal), visualization (equal), writing – original draft (equal). Chun‐Pin Esther Chang: conceptualization (equal), methodology (equal), software (equal), writing – review and editing (equal). Nathan D. Wong: writing – review and editing (equal). Roch A. Nianogo: writing – review and editing (equal). Jianyu Rao: writing – review and editing (equal). Thomas Varghese: writing – review and editing (equal). Zuo‐Feng Zhang: writing – review and editing (equal). Mia Hashibe: conceptualization (equal), funding acquisition (equal), investigation (equal), methodology (equal), project administration (equal), supervision (equal), writing – review and editing (equal).
Funding
This work was partially supported by the National Institutes of Health/National Cancer Institute (R01 CA244326).
Ethics Statement
This is an observational study. We obtained approval for this study from the University of Utah Institutional Review Board (IRB number: 151848).
Consent
Under the IRB regulations, this study received approval for waiver of informed consent.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Table S1: Distribution of matching factors of ANHPI and NHW lung cancer survivors.
Table S2: Hazard ratio (HR) and 95% confidence intervals (CIs) of depression, ANHPI/ANHPI ethnic groups vs. NHWa or Chineseb lung cancer patients, stratified by years after lung cancer diagnosis.
Table S3: Hazard ratio (HR) and 95% confidence intervals (CIs) for depression, ANHPI/ANHPI ethnic groups vs. NHWa or Chineseb lung cancer patients, Fine‐Gray Method to account for competing risk of death.
Table S4: The number of claims after lung cancer diagnosis of Asian, NHPI, and NHW patients with lung cancer.
Table S5: Hazard ratio (HR) and 95% confidence intervals (CIs) of depression, ANHPI/ANHPI ethnic groups vs. NHW or Chinese lung cancer patients, in three models of adjustment.
Table S6: Mental status rating results among Asian, NHPI, NHW Patients with lung cancer and medicare beneficiaries from SEER‐CAHPS.
Table S7: Marginal and stratified odds ratios (OR) and confidence intervals (CIs) of rate mental status results, comparing ANHPI to NHW individuals from SEER‐CAHPS, by cancer status or plan type.
Acknowledgments
This study used the linked SEER‐Medicare database and SEER‐CAHPS database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the National Cancer Institute; the Office of Research, Development and Information, Centers for Medicare & Medicaid Services (CMS); Information Management Services (IMS) Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries for the creation of the SEER‐Medicare and SEER‐CAHPS database. The collection of cancer incidence data used in this study was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by the California Health and Safety Code Section 103885; the National Cancer Institute's Surveillance, Epidemiology and End Results Program under contract HHSN261201000140C awarded to the Cancer Prevention Institute of California, contract HHSN261201000035C awarded to the University of Southern California, and contract HHSN261201000034C awarded to the Public Health Institute; and the Centers for Disease Control and Prevention's National Program of Cancer Registries, under agreement #U58DP003862‐01 awarded to the California Department of Public Health. The ideas and opinions expressed herein are those of the author(s) and endorsement by the California Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their Contractors and Subcontractors is not intended nor should be inferred. The authors acknowledge the efforts of the National Cancer Institute; the Office of Research, Development and Information, CMS; Information Management Services (IMS) Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER‐Medicare database and the SEER‐CAHPS database. The computational resources used were partially funded by the NIH Shared Instrumentation Grant 1S10OD021644‐01A1.
Data Availability Statement
The datasets used to conduct this study are available upon approval of a research protocol from the National Cancer Institute. Instructions for obtaining these data are available at https://healthcaredelivery.cancer.gov/seermedicare/obtain/ and https://healthcaredelivery.cancer.gov/seer‐cahps/obtain/.
References
- 1. Cancer Facts & Figures, 2024 Annual Report (American Cancer Society, 2024), https://www.cancer.org/research/cancer‐facts‐statistics/all‐cancer‐facts‐figures/2024‐cancer‐facts‐figures.html. [Google Scholar]
- 2. Kratzer T. B., Bandi P., Freedman N. D., et al., “Lung Cancer Statistics, 2023,” Cancer 130, no. 8 (2024): 1330–1348, 10.1002/cncr.35128. [DOI] [PubMed] [Google Scholar]
- 3. Cancer Facts & Figures, 2023 Annual Report (American Cancer Society, 2023), https://www.cancer.org/research/cancer‐facts‐statistics/all‐cancer‐facts‐figures/2023‐cancer‐facts‐figures.html. [Google Scholar]
- 4. Prevalence of Major Depressive Episode Among Adults, Major Depression (NIH Mental Health Information, 2023), https://www.nimh.nih.gov/health/statistics/major‐depression#:~:text=Prevalence%20of%20Major%20Depressive%20Episode%20Among%20Adults. [Google Scholar]
- 5. Prevalence of Depression Among Adults Aged 20 and Over: United States, 2013–2016 (CDC National Center for Health Statistics, 2018), https://www.cdc.gov/nchs/products/databriefs/db303.htm. [PubMed] [Google Scholar]
- 6. National, State‐Level, and County‐Level Prevalence Estimates of Adults Aged ≥18 Years Self‐Reporting a Lifetime Diagnosis of Depression—United States, 2020 (CDC Morbidity and Mortality Weekly Report (MMWR), 2023), https://www.cdc.gov/mmwr/volumes/72/wr/mm7224a1.htm. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Kessler R. C., Berglund P., Demler O., et al., “The Epidemiology of Major Depressive Disorder: Results From the National Comorbidity Survey Replication (NCS‐R),” Journal of the American Medical Association 289, no. 23 (2003): 3095–3105, 10.1001/jama.289.23.3095. [DOI] [PubMed] [Google Scholar]
- 8. Shimizu K., Nakaya N., Saito‐Nakaya K., et al., “Clinical Biopsychosocial Risk Factors for Depression in Lung Cancer Patients: A Comprehensive Analysis Using Data From the Lung Cancer Database Project,” Annals of Oncology 23, no. 8 (2012): 1973–1979, 10.1093/annonc/mds061. [DOI] [PubMed] [Google Scholar]
- 9. Hung M. S., Chen I. C., Lee C. P., et al., “Incidence and Risk Factors of Depression After Diagnosis of Lung Cancer: A Nationwide Population‐Based Study,” Medicine (Baltimore) 96, no. 19 (2017): e6864, 10.1097/MD.0000000000006864. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Lee M. J., Huang C. W., Lee C. P., et al., “Investigation of Anxiety and Depressive Disorders and Psychiatric Medication Use Before and After Cancer Diagnosis,” Psycho‐Oncology 30, no. 6 (2021): 919–927, 10.1002/pon.5672. [DOI] [PubMed] [Google Scholar]
- 11. ACTION Study Group , “Health‐Related Quality of Life and Psychological Distress Among Cancer Survivors in Southeast Asia: Results From a Longitudinal Study in Eight Low‐ and Middle‐Income Countries,” BMC Medicine 15, no. 1 (2017): 10, 10.1186/s12916-016-0768-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Park B., Youn S., Yi K. K., Lee S. Y., Lee J. S., and Chung S., “The Prevalence of Depression Among Patients With the Top Ten Most Common Cancers in South Korea,” Psychiatry Investigation 14, no. 5 (2017): 618–625, 10.4306/pi.2017.14.5.618. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Patel P. B., Alpert N., Taioli E., and Flores R., “Disparities in Clinical and Demographic Characteristics Among Asian/Pacific Islander and Non‐Hispanic White Newly Diagnosed Lung Cancer Patients,” Cancer Causes & Control 33, no. 4 (2022): 547–557, 10.1007/s10552-021-01548-5. [DOI] [PubMed] [Google Scholar]
- 14. Gomez S. L., Glaser S. L., Horn‐Ross P. L., et al., “Cancer Research in Asian American, Native Hawaiian, and Pacific Islander Populations: Accelerating Cancer Knowledge by Acknowledging and Leveraging Heterogeneity,” Cancer Epidemiology, Biomarkers & Prevention 23, no. 11 (2014): 2202–2205, 10.1158/1055-9965.EPI-14-0624. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Park M., “A Brief Review of Mental Health Issues Among Asian and Pacific Islander Communities in the U.S,” Asian/Pacific Island Nursing Journal 5, no. 4 (2021): 248–250, 10.31372/20200504.1124. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Oh E. G., Huang A. W., and Nguyen K. H., “Inequities in Patient Access to Care Among Asian American, Native Hawaiian, and Pacific Islander Adults in Medicaid,” Journal of Racial and Ethnic Health Disparities 11, no. 5 (2024): 2538–2552, 10.1007/s40615-023-01719-x. [DOI] [PubMed] [Google Scholar]
- 17. SEER‐Medicare: Brief Description of the SEER‐Medicare Database (NIH Division of Cancer Control and Population Sciences, 2026), https://healthcaredelivery.cancer.gov/seermedicare/medicare/. [Google Scholar]
- 18. Pan Y., Chang C. E., Tao R., et al., “Cardiovascular Disease Risk Among Older Asian, Native Hawaiian, Pacific Islanders Lung Cancer Survivors,” Cancer Medicine 14, no. 4 (2025): e70702, 10.1002/cam4.70702. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Pan Y., “Bidirectional Relationships Between Cardiovascular Disease and Lung Cancer, and Racial Disparities of Cardiovascular Disease and Depression in Lung Cancer Patients,” (Dissertation No. 32043077, ProQuest document ID: 3213623892) [Doctoral dissertation, University of California, Los Angeles] (2025), https://www.proquest.com/docview/3213623892.
- 20. “Chronic Conditions, Chronic Conditions Data Warehouse, CMS Medicare and Medicaid Research Data,” (2006), https://www2.ccwdata.org/web/guest/condition‐categories‐chronic.
- 21. “Comorbidity SAS Macro (2021 Version), NIH Division of Cancer Control and Population Sciences,” (2021), https://healthcaredelivery.cancer.gov/seermedicare/considerations/macro‐2021.html.
- 22. Batyrbekova N., Bower H., Dickman P. W., et al., “Modelling Multiple Time‐Scales With Flexible Parametric Survival Models,” BMC Medical Research Methodology 22, no. 1 (2022): 290, 10.1186/s12874-022-01773-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Kalibatseva Z. and Leong F. T., “Depression Among Asian Americans: Review and Recommendations,” Depression Research and Treatment 2011 (2011): 320902, 10.1155/2011/320902. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Takeuchi D. T., Chung R. C., Lin K. M., et al., “Lifetime and Twelve‐Month Prevalence Rates of Major Depressive Episodes and Dysthymia Among Chinese Americans in Los Angeles,” American Journal of Psychiatry 155, no. 10 (1998): 1407–1414, 10.1176/ajp.155.10.1407. [DOI] [PubMed] [Google Scholar]
- 25. Jackson J. S., Abelson J. M., Berglund P. A., Mezuk B., Torres M., and Zhang R., “Ethnicity, Immigration, and Cultural Influences on the Nature and Distribution of Mental Disorders: An Examination of Major Depression,” in Conceptual Evolution of DSM‐5, ed. Regier D., Narrow W., Kuhl E., and Kupfer D. (American Psychiatric Publishing, 2011), 267–285. [Google Scholar]
- 26. Misra S., Wyatt L. C., Wong J. A., et al., “Determinants of Depression Risk Among Three Asian American Subgroups in New York City,” Ethnicity & Disease 30, no. 4 (2020): 553–562, 10.18865/ed.30.4.553. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Kim H. J., Park E., Storr C. L., Tran K., and Juon H. S., “Depression Among Asian‐American Adults in the Community: Systematic Review and Meta‐Analysis,” PLoS One 10, no. 6 (2015): e0127760, 10.1371/journal.pone.0127760. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Kim M. T., Kim K. B., Han H. R., Huh B., Nguyen T., and Lee H. B., “Prevalence and Predictors of Depression in Korean American Elderly: Findings From the Memory and Aging Study of Koreans (MASK),” American Journal of Geriatric Psychiatry 23, no. 7 (2015): 671–683, 10.1016/j.jagp.2014.11.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29. Bernstein K., Lee Y. M., Gona P. N., Han S., Kim S., and Kim S. S., “Depression, Depression Literacy, and Sociodemographic Characteristics of Korean Americans: A Preliminary Investigation,” Journal of Immigrant and Minority Health 23, no. 3 (2021): 547–557, 10.1007/s10903-020-01092-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30. Fogel J. and Ford D. E., “Stigma Beliefs of Asian Americans With Depression in an Internet Sample,” Canadian Journal of Psychiatry 50, no. 8 (2005): 470–478, 10.1177/070674370505000807. [DOI] [PubMed] [Google Scholar]
- 31. Cheng Z. H., “Asian Americans and European Americans' Stigma Levels in Response to Biological and Social Explanations of Depression,” Social Psychiatry and Psychiatric Epidemiology 50, no. 5 (2015): 767–776, 10.1007/s00127-014-0999-5. [DOI] [PubMed] [Google Scholar]
- 32. Subica A. M., Aitaoto N., Sullivan J. G., Henwood B. F., Yamada A. M., and Link B. G., “Mental Illness Stigma Among Pacific Islanders,” Psychiatry Research 273 (2019): 578–585, 10.1016/j.psychres.2019.01.077. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33. Jung H., Cho Y. J., Rhee M. K., and Jang Y., “Stigmatizing Beliefs About Depression in Diverse Ethnic Groups of Asian Americans,” Community Mental Health Journal 56, no. 1 (2020): 79–87, 10.1007/s10597-019-00481-x. [DOI] [PubMed] [Google Scholar]
- 34. Kim S. B. and Lee Y. J., “Factors Associated With Mental Health Help‐Seeking Among Asian Americans: A Systematic Review,” Journal of Racial and Ethnic Health Disparities 9, no. 4 (2022): 1276–1297, 10.1007/s40615-021-01068-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35. Chaballout B. H., Wu T. C., Farrell M. J., et al., “Trends in Racial and Ethnic Disparities in Health‐Related Quality of Life in Older Adults With Lung Cancer,” Journal of Geriatric Oncology 15, no. 8 (2024): 102066, 10.1016/j.jgo.2024.102066. [DOI] [PubMed] [Google Scholar]
- 36. Farias A. J., Chan E., Navarro S., David E. A., Eguchi M., and Cockburn M., “Lung Cancer Mortality Racial/Ethnic Disparities in Patient Experiences With Care: A SEER‐CAHPS Study,” Journal of Racial and Ethnic Health Disparities 10, no. 4 (2023): 1745–1755, 10.1007/s40615-022-01358-8. [DOI] [PubMed] [Google Scholar]
- 37. Sullivan D. R., Forsberg C. W., Ganzini L., et al., “Depression Symptom Trends and Health Domains Among Lung Cancer Patients in the CanCORS Study,” Lung Cancer 100 (2016): 102–109, 10.1016/j.lungcan.2016.08.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38. Deng L. and Chen B., “Two‐Scale Assessment of Anxiety and Depression in Postoperative Non‐Small Cell Lung Cancer Patients: Their Prevalence, Risk Factors, and Prognostic Potency,” Irish Journal of Medical Science 192, no. 6 (2023): 2613–2619, 10.1007/s11845-023-03321-w. [DOI] [PubMed] [Google Scholar]
- 39. Gonzalez‐Ling A., Galindo Vázquez O., Espinoza Bello M., et al., “Quality of Life, Anxiety, Depression, and Distress in Patients With Advanced and Metastatic Lung Cancer,” Palliative & Supportive Care 21, no. 4 (2023): 608–615, 10.1017/S147895152200116X. [DOI] [PubMed] [Google Scholar]
- 40. Leung B., Laskin J., Wu J., Bates A., and Ho C., “Assessing the Psychosocial Needs of Newly Diagnosed Patients With Nonsmall Cell Lung Cancer: Identifying Factors Associated With Distress,” Psycho‐Oncology 28, no. 4 (2019): 815–821, 10.1002/pon.5025. [DOI] [PubMed] [Google Scholar]
- 41. Stabellini N., Bruno D. S., Dmukauskas M., et al., “Sex Differences in Lung Cancer Treatment and Outcomes at a Large Hybrid Academic‐Community Practice,” JTO Clinical and Research Reports 3, no. 4 (2022): 100307, 10.1016/j.jtocrr.2022.100307. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42. Park S., Kang C. H., Hwang Y., et al., “Risk Factors for Postoperative Anxiety and Depression After Surgical Treatment for Lung Cancer†,” European Journal of Cardio‐Thoracic Surgery 49, no. 1 (2016): e16–e21, 10.1093/ejcts/ezv336. [DOI] [PubMed] [Google Scholar]
- 43. Patnaik J. L., Byers T., DiGuiseppi C., Dabelea D., and Denberg T. D., “Cardiovascular Disease Competes With Breast Cancer as the Leading Cause of Death for Older Females Diagnosed With Breast Cancer: A Retrospective Cohort Study,” Breast Cancer Research 13, no. 3 (2011): R64, 10.1186/bcr2901. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44. “SEER Acknowledgment of Treatment Data Limitations,” (2020), https://seer.cancer.gov/data‐software/documentation/seerstat/nov2020/treatment‐limitations‐nov2020.html.
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1: Distribution of matching factors of ANHPI and NHW lung cancer survivors.
Table S2: Hazard ratio (HR) and 95% confidence intervals (CIs) of depression, ANHPI/ANHPI ethnic groups vs. NHWa or Chineseb lung cancer patients, stratified by years after lung cancer diagnosis.
Table S3: Hazard ratio (HR) and 95% confidence intervals (CIs) for depression, ANHPI/ANHPI ethnic groups vs. NHWa or Chineseb lung cancer patients, Fine‐Gray Method to account for competing risk of death.
Table S4: The number of claims after lung cancer diagnosis of Asian, NHPI, and NHW patients with lung cancer.
Table S5: Hazard ratio (HR) and 95% confidence intervals (CIs) of depression, ANHPI/ANHPI ethnic groups vs. NHW or Chinese lung cancer patients, in three models of adjustment.
Table S6: Mental status rating results among Asian, NHPI, NHW Patients with lung cancer and medicare beneficiaries from SEER‐CAHPS.
Table S7: Marginal and stratified odds ratios (OR) and confidence intervals (CIs) of rate mental status results, comparing ANHPI to NHW individuals from SEER‐CAHPS, by cancer status or plan type.
Data Availability Statement
The datasets used to conduct this study are available upon approval of a research protocol from the National Cancer Institute. Instructions for obtaining these data are available at https://healthcaredelivery.cancer.gov/seermedicare/obtain/ and https://healthcaredelivery.cancer.gov/seer‐cahps/obtain/.