Abstract
Chinese immigrants have high rates of a variety of cancers and face numerous social and economic barriers to cancer treatment appointment keeping. This study is a nested cohort of 82 Chinese patients participating in the Immigrant Cancer Portal Project. Twenty-two percent reported having missed appointments for oncology follow-up, radiation therapy, and/or chemotherapy. Patients most commonly reported needing assistance with financial support to enable appointment keeping. Efforts to further address social and economic correlates in cancer care should be developed for this population.
Introduction
Some 12.6% of the total US population is immigrant. China, after Mexico, is the second largest sending country.1 Asian Americans are the only major population group in the United States for whom the annual number of cancer deaths is greater than that for heart disease.2
Much effort has focused on increasing access to screening for minority and underserved populations, including the Chinese population.3,4 Several authors show that, after adjusting for diagnostic stage, substantial disparities in cancer survival remain among minority populations in general, indicating that other, post-diagnostic factors contribute to the mortality differentials.3,5–7 Low rates of cancer treatment appointment keeping, lower rates of receipt of adjuvant therapy, and early treatment termination have been described.3,8–18 However, these studies largely focus on black and Hispanic minority populations, with few authors examining disparities in treatment and survival among Asians. There are no studies assessing cancer treatment appointment keeping among Chinese immigrants.
Minorities are confronted with considerable social and economic barriers to cancer treatment appointment keeping, including poor housing, employment limitations, limited access to health insurance, cost of treatment, lack of child care and transportation, and inadequate nutrition.3 The Chinese population is subject to all of these barriers, plus language barriers, additional cultural factors, and other economic, personal, and family health priorities.19 Socioeconomic factors can significantly impact access to cancer treatment and appointment keeping and have been shown to affect treatment to significantly impact survival in minorities.8,20,21 Few studies have focused on assessing and addressing socioeconomic correlates of cancer treatment appointment keeping.
This study was conducted to specifically determine social and economic correlates of cancer treatment appointment keeping among Chinese immigrants.
Methods
The Immigrant Cancer Portal Project is a program funded by the New York Community Trust to provide assistance to largely low-income, immigrant, and minority patients in 11 New York City hospital cancer clinics where treatment appointment keeping had been noted to be problematic. Most patients at these sites prefer to communicate in languages other than English, most often in Chinese and Spanish. This study is a nested cohort of all Chinese patients participating in the Portal Project between 2008 and 2009, their areas of needed assistance, and appointment keeping for cancer treatment.
Central to the Portal intervention is the trained, bilingual access facilitator who assesses needs and coordinates an individualized set of transdisciplinary services for each patient. Access facilitators operate in a breadth of areas, ranging from assessing and prioritizing needs; providing assistance with intake procedures to patients with low literacy and limited English proficiency; providing financial support, i.e., assisting with obtaining reimbursements and funding that may go towards doctor’s visits, radiation therapy, chemotherapy, radiological scans, pain medications, medical supplies, and home care; addressing food insecurity; assisting with transportation; assisting with rent support and housing conditions; assisting with accessing programs that provide free medications; assisting with insurance and obtaining mandated hospital fee reductions; accessing free or low-cost legal resources for immigration, eviction, wills, and work discrimination concerns; assisting with referrals to social services, counseling, and cancer support groups; assisting with accessing child care for appointments; accessing and working with interpreters; and helping patients improve patient–provider communication.
Eligible patients in the nested cohort included all English, Mandarin, Cantonese, and Fukianese-speaking immigrant adults with Chinese ancestry with a diagnosis of cancer who were undergoing treatment. Facilitators approached all patients in the waiting area prior to their medical visits. As part of the patients’ care, access facilitators conducted a needs assessment survey in the patient’s preferred language. The needs assessment included sociodemographic indicators; need for socioeconomic assistance (financial support, food, transportation, rent, medications, insurance issues, legal issues, social and psychosocial services, and child care); reports of missed oncology, radiation therapy, and/or chemotherapy appointments and the reason(s) why. Once patient needs were identified, facilitators provided immediate and ongoing assistance in those areas.
We performed descriptive statistics to examine sociodemographic characteristics, areas of needed assistance, and missed appointments.
Results
Six hundred eighty-nine patients with cancers of all sites were enrolled in the study between July 2008 and July 2009. One hundred ten Chinese immigrant patients were approached; 25% refused help, and 82 agreed to participate. All had immigrated from China, Hong Kong, or Taiwan; 52% had resided in the United States for 10 years or less. Forty percent had not completed high school, and nearly all preferred to speak Chinese in the health care setting. Twenty-seven (33%) had no health insurance, and 49 (60%) were insured (three responded “Don’t know” and three responses were missing). Of the 49 patients who did have insurance, 27 (55%) had Medicaid and 13 (27%) had Emergency Medicaid. Only 23% reported working with a social worker (Table 1).
Table 1.
Sociodemographic characteristics (n = 82)
| Age, years | n (%) |
|---|---|
| 18–29 | 6 (7) |
| 30–49 | 19 (23) |
| 50–69 | 44 (55) |
| 70–79 | 10 (12) |
| >80 | 2 (2) |
| Gender | |
| Male | 31 (38) |
| Female | 51 (62) |
| Education | |
| ≤5th | 16 (20) |
| Grade 6 to some HS | 16 (20) |
| HS graduate | 23 (28) |
| Some college to post-college | 19 (23) |
| Missing | 8 (10) |
| Country of origin | |
| China | 79 (96) |
| Hong Kong | 2 (2) |
| Taiwan | 1 (1) |
| Years in USA | |
| <1 year | 6 (7) |
| 1–3 years | 15 (18) |
| 4–5 years | 6 (7) |
| 6–10 years | 16 (20) |
| 11–20 years | 31 (38) |
| >20 years | 8 (10) |
| Language preferred | |
| English | 1 (1) |
| Cantonese | 10 (12) |
| Mandarin | 61 (74) |
| Other Chinese dialects | 10 (12) |
| Do you have insurance? | |
| Yes | 49 (60) |
| No | 27 (33) |
| Don't know | 3 (4) |
| Missing | 3 (4) |
| If yes, what type of insurance? | |
| Medicaid | 27 (55) |
| Medicare | 8 (16) |
| Private insurance | 1 (2) |
| Emergency Medicaid | 13 (27) |
| Are you working with a social worker? | |
| Yes | 19 (23) |
| No | 61 (74) |
| Don't know | 1 (1) |
| Missing | 1 (1) |
Among all those enrolled, patients most commonly reported needing assistance in the following areas to help them attend appointments: financial support (87%), food support (18%), and transportation (18%). Nine percent reported needing assistance with health insurance issues. Twenty-two percent reported that they had missed appointments for oncology follow-up, radiation therapy, and/or chemotherapy. Among the 18 patients who had missed appointments, 94% reported they needed financial support. Among the 62 patients who had not missed appointments, 79% needed financial support. Two responses were missing for this question on missed appointments (Table 2). Additionally, stated reasons for missing appointments included misunderstanding of when the appointment was scheduled, conflicts with other appointments, and patients being too weak to attend appointments. There were no sociodemographic differences between those who had reported versus those who had not reported missing appointments.
Table 2.
Cancer diagnoses, missed appointments, areas of portal assistance (n = 82)
| Diagnosis | n (%) |
|---|---|
| Breast | 22 (27) |
| Gynecological | 6 (7) |
| Gastrointestinal | 26 (32) |
| Head and neck | 6 (7) |
| Lung | 10 (12) |
| Other | 9 (11) |
| Don’t know | 2 (2) |
| Missing | 1 (1) |
| Have you missed any appointments? | |
| Yes | 18 (22) |
| No | 62 (76) |
| Missing | 2 (2) |
| Areas of assistance | |
| Financial support | 71 (87) |
| Food support | 15 (18) |
| Transportation | 15 (18) |
| Rent support | 13 (16) |
| Accessing programs for free medications | 10 (12) |
| Health insurance issues | 7 (9) |
| Legal services/immigration-related issues | 7 (9) |
| Social work services | 3 (4) |
| Psychosocial support | 3 (4) |
| Housing conditions | 3 (4) |
| Child care | 2 (2) |
| Other | 12 (15) |
| Refused | 1 (1) |
Discussion
In this nested cohort of 82 Chinese immigrant cancer patients, we found a high number of patients who reported missed appointments for follow-up care and treatment. Some of the reported reasons for missing appointments, such as misunderstanding of when the appointment was scheduled and conflicts with other appointments, could be addressed by ensuring available and accurate interpreting/translation services at the time of appointment scheduling or through the presence of bilingual staff and/or patient navigators. Patients most commonly reported needing financial support. Only 23% of patients had been working with a social worker at the time of study enrollment, indicating that patients were either not aware of, or not willing or able to (due to language barriers or resource scarcity), access available resources. Strategies such as provider reminders, patient education, and automated referrals to linguistically responsive social services could potentially address this. This study likely underestimated the missed appointment rate, as we performed a cross-sectional survey of patients who were present at the clinic for follow-up. Patients who missed more appointments were less likely to have been enrolled in the study. Additionally, as the study was based on self-report of missed appointments, accuracy may have been affected by poor patient recall. A larger, prospective study is needed that tracks patients from intake through treatment and assesses their reported concerns and objective measures of appointment keeping.
Targeting social and economic correlates of cancer treatment appointment keeping in minority and underserved populations is an area that has received little attention, yet may be essential in improving the disparities in cancer outcomes seen in minority and underserved populations. Chinese immigrants are a particularly vulnerable and understudied group, with high rates of a variety of cancers and multiple barriers to care. Efforts to further address social and economic correlates in cancer care should be developed and implemented for this population. The socioeconomic barriers to cancer treatment described in this study have been reported in other minority populations.20,22 Our Immigrant Cancer Portal Project begins to address these significant concerns and may potentially serve as a model for replication in other vulnerable communities.
Acknowledgments
The work described was supported by the New York Community Trust. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the awarding Agencies.
References
- 1.US Census Bureau. The foreign-born population: 2000. Census 2000 Brief. Available at: https://www.census.gov/prod/2003pubs/c2kbr-34.pdf. Accessed February 3, 2010.
- 2.American Cancer Society. Cancer hits US Asian groups differently. Available at: http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Cancer_Hits_US_Asian_Groups_Differently.asp. Accessed May 10, 2009.
- 3.Shavers VL, Brown ML. Racial and ethnic disparities in the receipt of cancer treatment. J Natl Cancer Inst. 2002;94(5):334–357. doi: 10.1093/jnci/94.5.334. [DOI] [PubMed] [Google Scholar]
- 4.Taylor VM, Hislop TG, Jackson JC, et al. A randomized controlled trial of interventions to promote cervical cancer screening among Chinese women in North America. J Natl Cancer Inst. 2002;94(9):670–677. doi: 10.1093/jnci/94.9.670. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Cooper GS, Yuan Z, Rimm AA. Racial disparity in the incidence and case-fatality of colorectal cancer: analysis of 329 United States counties. Cancer Epidemiol Biomark Prev. 1997;6(4):283–285. [PubMed] [Google Scholar]
- 6.Vernon SW, Tilley BC, Neale AV, Steinfeldt L. Ethnicity, survival, and delay in seeking treatment for symptoms of breast cancer. Cancer. 1985;55(7):1563–1571. doi: 10.1002/1097-0142(19850401)55:7<1563::AID-CNCR2820550726>3.0.CO;2-1. [DOI] [PubMed] [Google Scholar]
- 7.McWhorter WP, Mayer WJ. Black/white differences in type of initial breast cancer treatment and implications for survival. Am J Public Health. 1987;77(12):1515–1517. doi: 10.2105/AJPH.77.12.1515. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Formenti SC, Meyerowitz BE, Ell K, Muderspach L, Groshen S, Leedham B, Klement V, Morrow PC. Inadequate adherence to radiotherapy in Latina immigrants with carcinoma of the cervix: potential impact on disease free survival. Cancer. 1995;75:1135–1140. doi: 10.1002/1097-0142(19950301)75:5<1135::AID-CNCR2820750513>3.0.CO;2-M. [DOI] [PubMed] [Google Scholar]
- 9.Bickell NA, LePar F, Wang JJ, Leventhal H. Lost opportunities: physicians’ reasons and disparities in breast cancer treatment. J Clin Oncol. 2007;25:2516–2521. doi: 10.1200/JCO.2006.09.5539. [DOI] [PubMed] [Google Scholar]
- 10.Bickell NA, Wang JJ, Oluwole S, et al. Missed opportunities: racial disparities in adjuvant breast cancer treatment. J Clin Oncol. 2006;24:1357–1362. doi: 10.1200/JCO.2005.04.5799. [DOI] [PubMed] [Google Scholar]
- 11.Xianglin L, Gor BJ. Racial disparities and trends in radiation therapy after breast-conserving surgery for earlystage breast cancer in women, 1992 to 2002. Ethn Dis. 2007;17:122–128. [PMC free article] [PubMed] [Google Scholar]
- 12.Joslyn SA. Racial differences in treatment and survival from early-stage breast carcinoma. Cancer. 2002;95:1759–1766. doi: 10.1002/cncr.10827. [DOI] [PubMed] [Google Scholar]
- 13.Li CI, Malone KE, Daling JR. Differences in breast cancer stage, treatment, and survival by race and ethnicity. Arch Intern Med. 2003;163:49–56. doi: 10.1001/archinte.163.1.49. [DOI] [PubMed] [Google Scholar]
- 14.Naeim A, Hurria A, Leake B, Maly RC. Do age and ethnicity predict breast cancer treatment received? A cross-sectional urban population based study. Breast cancer treatment: age and ethnicity. Crit Rev Oncol Hematol. 2006;59:234–242. doi: 10.1016/j.critrevonc.2006.03.002. [DOI] [PubMed] [Google Scholar]
- 15.Hershman D, McBride R, Jacobson JS, et al. Racial disparities in treatment and survival among women with early stage breast cancer. J Clin Oncol. 2005;23:6639–6646. doi: 10.1200/JCO.2005.12.633. [DOI] [PubMed] [Google Scholar]
- 16.Tammemagi CM. Racial/ethnic disparities in breast and gynecologic cancer treatment and outcomes. Curr Opin Obstet Gynecol. 2007;19:31–36. doi: 10.1097/GCO.0b013e3280117cf8. [DOI] [PubMed] [Google Scholar]
- 17.Byers TE, Wolf HJ, Bauer MS, et al. The impact of socioeconomic status on survival after cancer in the United States. Cancer. 2008;5:241–246. doi: 10.1002/cncr.23567. [DOI] [PubMed] [Google Scholar]
- 18.Kim SH, Ferrante J, Won BR, Hammeed M. Barriers to adequate follow-up during adjuvant therapy may be important factors in the worse outcome for black women after breast cancer treatment. J Surg Oncol. 2008;6:26–29. doi: 10.1186/1477-7819-6-26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Ferrante JM, Chen PH, Kim S. The effect of patient navigation on time to diagnosis, anxiety, and satisfaction in urban minority women with abnormal mammograms: a randomized controlled trial. J Urban Health. 2008;85(1):114–124. doi: 10.1007/s11524-007-9228-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Guidry JJ, Aday LA, Zhang D, Winn RJ. Cost considerations as potential barriers to cancer treatment. Cancer Pract. 1998;6(3):182–187. doi: 10.1046/j.1523-5394.1998.006003182.x. [DOI] [PubMed] [Google Scholar]
- 21.Du XL, Fang S, Meyer TE. Impact of treatment and socioeconomic status on racial disparities in survival among older women with breast cancer. Am J Clin Oncol. 2008;31(2):125–132. doi: 10.1097/COC.0b013e3181587890. [DOI] [PubMed] [Google Scholar]
- 22.Formenti SC, Meyerowitz BE, Ell K, et al. Inadequate adherence to radiotherapy in Latina immigrants with carcinoma of the cervix: potential impact on disease free survival. Cancer. 1995;75:1135–1140. doi: 10.1002/1097-0142(19950301)75:5<1135::AID-CNCR2820750513>3.0.CO;2-M. [DOI] [PubMed] [Google Scholar]