Do Doctors Know How to Talk to Asian Americans About Cancer
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Asian Americans are often perceived as being healthier than their peers, a misconception propelled by the model minority myth — a 1960s racial myth that suggests Asian Americans as a whole are more successful when it comes to education, finances, and health compared with other racial and ethnic groups, according to a study published in Ethnicity and Disease. The reality is that Asian American illness is simply not talked about enough, and that’s especially true when it comes to cancer.
“A lot of people don’t know that Asian Americans face a very different disease burden, particularly with respect to cancers, compared with non-Hispanic white and other non-Asian populations,” says Dr. Robert Huang, MD, a gastroenterologist at Stanford Health Care in California. “It’s really a disservice that this information is not better publicized or better known,” he says.
Dr. Huang explains that as a whole group, Asian Americans have a higher incidence and mortality rate of certain cancers compared with white Americans. Cancer is the leading cause of death for Asian American men, according to the CDC, while for all other ethnicities, it’s heart disease. In women, while cancer is the leading cause of death for Hispanic and Indigenous women as well, it’s Asian American and Pacific Islander women who lead the pack with the highest death rates attributable to cancer, the CDC also states.
Some of these numbers become even more stark if you zoom in on the data and look at specific Asian ethnicities. For example, a study conducted by Huang and published in February 2021 in the International Journal of Cancer found that the rate of gastrointestinal cancer deaths among Asians can vary widely: 5.5 percent for Indian Americans versus 14.4 percent for Korean Americans.
“[All] Asians are not the same. They have different genetic backgrounds, different lifestyles, diets, and they may face different risk factors,” Huang says. “Because of that, there is a real need to [separate out the different groups of] Asians to study disease patterns. Traditionally, Asians have been [grouped together] into one large group for study. But … [that] really doesn’t get at the diversity, and it’s not doing a service to public health either.”
Overall, there are fewer people dying from cancer compared with twenty years ago, largely thanks to advances in medicine, according to CNN News. Still, cancer is a persistent problem for the Asian American community.
Everyday Health sat down with Huang to speak more about the differences between treating first-generation and second-generation Asian American patients, and the importance of talking to your primary care doctor about risk factors, screenings, and early prevention.
Everyday Health: How do you approach talking about cancer with your older, first-generation Asian American patients?
Robert Huang: That’s a really tough conversation to have sometimes. A lot of Asian families don’t necessarily want their family member who was diagnosed with cancer to know they have cancer.
We see this very frequently in the hospital where you have an older Asian person diagnosed with cancer. Often, they don’t speak English that well, and in many parts of Asia it’s accepted that you don’t tell your parents, if they get cancer, that they’re about to die. You just keep taking care of them. The children take care of it and make the decisions because that’s how Asian culture works.
But in America, it’s hard to do that. We have to follow a certain code of ethics. And we have to ask patients what they want in terms of their treatment and their preferences. So that tension occurs a lot. It’s not something that I think a lot of non-Asians know about or appreciate.
It’s done with the right intentions, with the intention of love and not wanting to cause psychological harm, or grief, or fear of death, but it flies in the face of our Western values and what we learn in medical school [about] patient autonomy. We were always taught that the patient has the right to know, to make the decisions.
EH: How do you manage follow-up care in those scenarios?
RH: What I’ve done in the past is I’ve asked the patient how they want to handle the communication — whether they want to know everything about their diagnosis, or whether they want their son or their daughter to hear the news and make the decisions.
Most of the patients that I have dealt with, they authorize their children to hear the news and make the decisions on their behalf. I’ve run this by an ethical consultant a couple of times and as long as the patient is aware that they have the option to know their diagnosis, and they have the option to decide on their management plan, but they choose voluntarily not to hear the diagnosis, and want their son or their daughter to make any treatment decisions, then I think we’re okay from an ethics standpoint. So that’s been a strategy that we’ve tried in the past.
EH: How is it different when you’re talking to second or third generation, younger Asian American patients who are diagnosed with cancer?
RH: The Asians who have grown up in America, the children of immigrants, I think they’re more Americanized, and I think the principles of autonomy are probably more dominant. So for the most part we let patients speak for themselves and know their diagnosis. They want to know, they want to be in charge of their treatment and make decisions. For the second generation and beyond, I don’t really notice a big difference between Asian and non-Asian patients in that sense. It’s really the first generation immigrants where this conflict is most apparent.
EH: What are some of the biggest challenges first-generation or recently immigrated Asian Americans face when trying to access cancer screenings and care?
RH: Language barriers, and finding a physician who speaks the language and is in tune with the culture is very difficult. Even in a place like the Bay Area [which has a particularly high Asian American population] it can be challenging, but I can imagine certainly outside of the Bay Area, it could be even harder. So language barriers, socio-economic issues, often a lack of insurance among immigrants, and then just overall lack of awareness of screening [are all challenges]. People may come from regions where there may not be stricter screenings, or preventative care has not been promoted like it has been in the United States. So there may not even be the awareness of routine preventative care. These are all barriers to cancer screening in this population.
EH: When it comes to the lack of screenings, do you see this as an issue with the patients not seeking them out, or is this a failing of the providers who are not bringing the screenings up?
RH: I think it’s really both. I think from the provider, there maybe isn’t that level of medical knowledge that different types of cancers affect different racial groups. So the providers may not be bringing this up to their patients.
And from the patient’s standpoint, I think we need to do a better job through public health awareness campaigns, or through other mechanisms, to educate our patients that they are at higher risk for certain types of cancers.
EH: A lot of hospitals say they have translators that patients can ask for. Have you found that to be true?
RH: I think it depends on the hospital. If you’re at Stanford [Medical Center] in Palo Alto, one of the poshest neighborhoods in the world [with a large Asian population], then yeah, there are enough translators to go around. But if, for example, you’re at one of the county hospitals, I think it’s much more difficult to get adequate translation services. So that remains an issue, the ability to navigate patients who don’t speak English to appropriate preventative services.
EH: Do you see a cultural difference between first generation and second generation immigrants when it comes to seeking care and talking about cancer risks?
RH: It does seem that with successive generations in the United States, the risk profile for cancer of Asian Americans seems to become more like that of the white population. For instance, the risk for stomach cancer in second generation Asian Americans is substantially lower than for first generation. And if you go out to the third generation — and there’s a little bit of data on this from the Japanese people living in Hawaii, since they’ve been there for so many generations now — the risk is starting to approach that of the white population.
On the other hand, the risk of other cancers tends to go up with successive generations. The best example of this is colorectal cancer. Colorectal cancer is strongly linked to red and processed meat consumption in the Western diet. And so with successive generations in the United States, it seems that the risk of colorectal cancer increases with acculturation. So it goes both ways.
In regards to [low] cancer screening [rates], part of it is acculturation, language barriers, and [lack of] education. First generation immigrants are going to be the most disadvantaged when it comes to these barriers to appropriate screening compared with their children, who speak better English and maybe have better access to care and health literacy.
EH: What are some cancer types that affect the Asian American population more than other racial or ethnic groups?
RH: I know the most about digestive cancers. One example is liver cancer. Liver cancer in Asian populations is often due to a chronic infection of the liver called Hepatitis B. Some Asian subgroups, for instance, like Vietnamese Americans, have some of the highest rates of liver cancer in the world.
Another example is gastric cancer. Gastric cancer is a big problem in certain Asian populations, including the Korean American, Japanese American, and Chinese American populations. Gastric cancer in these populations is due to an infection by a bug that infects the stomach called Helicobacter pylori.
One more is nonsmoking lung cancer. There is a very high rate of lung cancer in nonsmoking Asian women [per UCSF]. This has to do with a genetic mutation that’s found in these cancers. In fact, the rate of nonsmoking lung cancer [in Asian women] is so high in Asia, that some regions perform screenings for it in the form of CT [computerized tomography] scans.
One other cancer I want to talk about is esophageal cancer. I’m sure you’ve had friends who, at parties when they drink alcohol, they turn red. They call it the Asian flush, but it’s actually a really significant risk factor for esophageal cancer.
EH: What advice do you have for Asian American patients seeking cancer care?
RH: Find a doctor you trust. It would be great to find a culturally concordant doctor but sometimes that’s very difficult, especially if you’re, say, a Cambodian American or Hmong American.
Know your family history, and your [family’s] cancer history, because that makes a difference, too. [Your cancer risk] may be due to shared genetics and may also be due to shared risk factors. That will help your doctor make good decisions about screening.
Finally, be an advocate for yourself. Your doctor may or may not know about differences in cancer burden between Asians and non-Asians. Don’t be afraid to ask your doctor, “As an Asian American, am I at higher risk for any cancers? And are there any particular screenings that you would recommend for me because of my race?”
EH: Are there any resources you recommend that could be helpful for this particular population?
RH: The Center for Asian Health Research and Education (CARE) at Stanford is one of the only institutions of its kind in the United States focused on Asian health. We have resources for patients about differences in cancer, distribution, and burden between Asian subgroups. We have a lecture series and we have community health talks focused on cancer differences. So I would recommend people visit that website.
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