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Asian/Pacific Islander American Women: Age and
Death Rates During Hospitalization for Breast Cancer
Carolee Polek, PhD, RN, Paula Klemm, DNSc, RN, OCN, Thomas Hardie, EdD, RN, CS, NP,
Erlinda Wheeler, DNS, RN, Margaret Birney, PhD, RN, and Kevin Lynch, PhD
Key Points . . .
Purpose/Objectives: To investigate whether differences in age and
death rates exist between hospitalized Asian/Pacific Islander American
(APIA) women and women of other racial groups.
The term Asian/Pacific Islander American (APIA) signifies a
Design: Secondary data analysis of a national data set.
diverse population in the United States.
Setting: The Healthcare Cost and Utilization Project Nationwide Inpa-
Death rates from breast cancer in the APIA population are sig-
tient Sample, Release 6, was used to obtain hospitalization data on
nificantly higher than rates among other ethnic populations.
women with breast cancer based on racial status. A total of 20,507 hos-
Some groups of APIA women present later and with more ad-
pitalization records met the study criteria.
Sample: All women who were hospitalized with a primary diagnosis
vanced disease than their Caucasian counterparts.
of breast cancer, were older than 18, and did not die during hospitaliza-
APIA women face a variety of barriers that may result in start-
tion, plus all women who met the criteria stated above but died during
ing and receiving treatment later in the disease course.
Methods: Secondary data analysis. Post hoc analysis was used to
identify significant differences among racial groups.
Findings: Significant differences were found between APIA and Cau-
in the United States has grown from 1.5 million in 1970 to more
casian and Latino women. Significant differences based on race were
than 11.2 million in 2000 (U.S. Census Bureau, 2000).
found between subjects who had died during hospitalization. On average,
Rates of breast cancer generally are lower in Asia than in the
APIA women were the youngest to die.
United States (Kagawa-Singer & Pourat, 2000). According to
Conclusions: APIA women with breast cancer were among the young-
est women being hospitalized and the youngest to die during hospitalization.
Jemal et al. (2004), the incidence of breast cancer in APIA
Implications for Nursing: Cultural awareness by nurses is critical when
women is 97.2 (per 100,000 women) compared to 140.8 for
discussing methods for prevention and early detection of breast cancer with
Caucasian women in the United States. The mortality rate is
minority women. Targeting new immigrants is a priority for those who
12.5 (per 100,000) compared to 27.2 for Caucasians (Jemal et
screen and educate women about detection and treatment of breast cancer.
al.). Evidence suggests that exposure to the Western lifestyle in-
creases breast cancer risk among immigrants from Asia (Ziegler
et al., 1993). The longer that foreign-born Asian/Pacific Is-
reast cancer is the most frequent cancer diagnosis for
lander women reside in the United States, the more likely that
women in the United States. Incidence remained rela-
their risk for developing breast cancer will approach that of
tively unchanged during the 1990s. Even so, an esti-
American-born women. Disease rates among APIA women
mated 217,440 women will be diagnosed and 40,580 will die of
vary depending on ethnicity. In general, however, these women
the disease in 2004 (Jemal et al., 2004). More Caucasians are
diagnosed with breast cancer than other groups. However, the
five-year relative survival rate in other races and ethnic minori-
Carolee Polek, PhD, RN, is an assistant professor, Paula Klemm, DNSc,
ties is substantially lower than that for Caucasians (Jemal et al.).
RN, OCN, is an associate professor, Thomas Hardie, EdD, RN, CS,
The term Asian American signifies a diverse population in the
NP, is an associate professor, Erlinda Wheeler, DNS, RN, is an assis-
United States. The federal government defines Asian Americans
tant professor, and Margaret Birney, PhD, RN, is an associate profes-
as a minority population originating in the Far East, Asia, and
sor, all in the College of Health and Nursing Sciences at the University
of Delaware in Newark; and Kevin Lynch, PhD, is an assistant profes-
Southeast Asia (Intercultural Cancer Council, 2001). According
sor in the School of Medicine, Department of Psychiatry, Treatment Re-
to the 2000 U.S. Census, Asian/Pacific Islander Americans
search Center, at the University of Pennsylvania in Philadelphia. (Sub-
(APIAs) are the fastest-growing ethnic group in the United
mitted January 2004. Accepted for publication February 12, 2004.)
States, with the population increasing by 72% since the 1990
U.S. Census (U.S. Census Bureau, 2000). The number of APIAs
Digital Object Identifier: 10.1188/04.ONF.E69-E74
have lower cancer incidence and mortality rates than Cauca-
American women born in the United States did not differ sig-
sians for all anatomic sites combined, but their survival rates are
nificantly from that of Caucasian American women overall.
poorer than those of Caucasians (Yi & Prows, 1996).
Racial differences in breast cancer mortality have been attrib-
uted to late-stage disease at diagnosis (Gullatte, 1999). This
contrasts with findings reported in most national databases
Literature Review
that indicate that APIA women present at earlier stages of
Rajaram and Rashidi (1998) reported that although minor-
disease than Hispanics or African Americans (Ortin, 1998).
ity women have higher breast cancer mortality rates, they are
Mitchell (1998) described cross-cultural issues in the dis-
less likely than Caucasian women to use screening proce-
closure of a cancer diagnosis and noted that many cultures
dures. Regardless of type of cancer, minority women typically
(e.g., ethnic Americans, including Korean and Chinese) con-
present with more advanced stages of disease than Caucasian
sider complete and accurate disclosure of cancer undesirable.
women (Phipps, Cohen, Sorn, & Braitman, 1999). Subse-
Bottorff et al. (1999) examined breast cancer screening prac-
quently, minority women are more likely than Caucasian
tices in a sample of 50 South Asian women living in Canada.
women to die from the disease (Yi & Prows, 1996). A study
The women provided five major explanations for how breast
comparing racial differences in breast cancer survival indi-
cancer developed: catching it, damaging the breast, passing it
cated that African American women were younger at time of
down, bringing it upon yourself, and through the hands of
diagnosis, had more advanced tumors, and had poorer survival
others. Facione, Giancarlo, and Chan (2000) studied 45 Chi-
rates than Caucasian women. The researchers attributed the
nese American women and found that the women in their
findings to socioeconomic factors, lower use of mammogra-
sample felt "invulnerable" to cancer and described cancer as
phy screening, and cultural barriers and beliefs (Joslyn &
"tragic luck" and mammography as bringing on trouble. Lu
West, 2000). Similar findings have been reported for APIA
(1995) recruited 174 Taiwanese women for a study designed
women (Ortin, 1998; Yi & Prows).
to explore variables associated with breast self-examination.
Asian American and Pacific Islander women have the low-
The subjects reported that they were not susceptible to breast
est breast cancer screening rates and increasing mortality rates
cancer and attributed the disease to fate, broken promises to
when compared with other ethnic groups (San Francisco State
a god, and hot and cold imbalances in the body.
University, 2001). Nationally, the two-year mammography
Early detection of breast cancer results in favorable out-
screening rate for APIA women aged 50 and older is 63% com-
comes. Unfortunately, underutilization of breast cancer screen-
pared to an overall national average of 69% (Clegg, Li, Hankey,
ing is cited as a common problem, with only 30% of Asian fe-
Chu, & Edwards, 2002). Breast cancer is the leading cause of
m a l e immigrants reporting that they have ever had a
death among APIA women, and death rates have increased al-
mammogram (Kagawa-Singer & Pourat, 2000). A survey of 39
most 200% since 1990 (Kagawa-Singer & Pourat, 2000).
Middle Eastern Asian Islamic immigrant women indicated that
Among certain groups in the APIA population, death rates from
85% had heard of breast self-examination but that 74% had not
breast cancer are significantly higher than rates among other
examined their breasts for lumps. None of the respondents had
ethnic populations (Intercultural Cancer Council, 2001).
examined their breasts monthly during the previous year
The APIA population poses unique healthcare challenges
(Rashidi & Rajaram, 2000).
because of increasing ethnic heterogeneity. APIAs are diverse
Tang, Solomon, and McCracken (2000) reported that health
in language, culture, history, religion, and demographic char-
insurance coverage and degree of acculturation were predic-
acteristics. When sociocultural health statistics are reported,
tors of whether women would have a mammogram at least
these groups often are lumped together. Linguistic and
once. The authors noted that other barriers included an East-
ethnocultural barriers to gaining healthcare and other services
ern approach to medicine, little interest in preventing disease,
are barriers to the APIA population, which is composed pri-
modesty, and reliance on family when seeking care. Rajaram
marily of recent immigrants and refugees. In the more than 30
and Rashidi (1999) explored breast cancer screening practices
different ethnic groups that comprise the U.S. Asian popula-
of Asian Islamic women in the United States and found that
tion (U.S. Census Bureau, 2000), breast cancer screening
cleanliness, individual responsibility in health promotion, diet,
practices are below recommended rates. This has been attrib-
eating habits, and exercise were associated with breast cancer
uted to degree of assimilation, level of education, language
screening. Factors associated with not screening for breast
fluency, geographic location, generation, occupation, and so-
cancer included time constraints, embarrassment, discomfort,
cioeconomic status (Facione & Katapodi, 2000; Joslyn &
and having to ask a physician for the procedure (Maxwell et
West, 2000).
al., 1998).
Maxwell, Bastani, and Warda (1998) indicated that some
Yi and Prows (1996) surveyed 216 Cambodian women in
groups of APIA women, including Koreans, Filipinos, and
the United States by telephone to help identify variables that
Native Hawaiians, present later and with more advanced dis-
might be associated with ever having had a clinical breast
ease than their Caucasian counterparts. Reasons attributed to
examination. The researchers identified perceived barriers
this include cultural values and beliefs affecting attitudes
such as income, written language acculturation, knowledge
about cancer prevention strategies, screening, and access to
about clinical breast examination recommendations, and level
health care. Hedeen and White (1999) explored whether Asian
of education in the United States as predictors of having a
American women with breast cancer presented at a more ad-
clinical breast examination at least once. Yi (1994) found that
vanced stage of disease at diagnosis compared to Caucasian
sociocultural preference, length of residence in the United
Americans. Their findings indicated that Asian-born Ameri-
States, age, and a regular place for care predicted mammog-
can women had a greater portion of tumors larger than 1 cm
raphy screening in a sample of Vietnamese women living in
at diagnosis than did Caucasian American women. In contrast,
Massachusetts. Maxwell et al. (1998) surveyed 229 Korean
the proportion of tumors larger than 1 cm among Asian
American women in California and found that subjects were
more likely to get a mammogram if they had an income
greater than $25,000 per year, a physician recommendation,
Two samples were examined to meet the aims of the study.
positive group norms, and a longer stay in the United States
The first sample included all women hospitalized in 1997 with
and had become acculturated. In contrast, Phipps et al. (1999)
a primary diagnosis of breast cancer who were 18 years of age
reported that length of stay in the United States was not a pre-
or older and did not die during hospitalization. Women who
dictor of getting a mammogram.
died during hospitalization were excluded from this sample to
Lack of health insurance has been cited as a possible reason
control potential skewing of the results. The second sample
that APIA women were not screened for breast cancer (Max-
included all women who met the same criteria but died dur-
well et al., 1998; Tang et al., 2000). A recent report indicated
ing hospitalization with a primary diagnosis of breast cancer.
that health insurance rates for employed and unemployed indi-
viduals fell in 2002, and an estimated 43.6 million people (15%
of the overall population) were without coverage (U.S. Census
Prior to data analysis, an evaluation was performed to de-
Bureau, 2003). The number of uninsured Asians was reported
termine whether the main assumptions underlying the meth-
to be 18%21% compared to 10% of Caucasians (Guy, 2000).
ods were satisfied. Using the recommendations of Tabach-
In addition, 33.4% of foreign-born citizens and 43.3% of for-
nick and Fidell (2001), the researchers checked the data for
eign-born noncitizens lacked health insurance in 2002 (U.S.
outliers and for normality of dependent variables in the cells
Census Bureau, 2003). Ayanian, Kohler, Abe, and Epstein
defined by the explanatory variables. In addition, the homo-
(1993) studied 4,675 women with invasive breast cancer and
geneity of variance-covariance matrices in those cells and
found that those who were uninsured or had Medicare presented
the linearity of independent-dependent variable relationships
with more advanced disease than women who had private in-
in the cells were determined. Age was examined for normal-
ity, and analysis of age in both samples employed a general
In general, lower rates of breast cancer screening and mul-
linear model univariate analysis of variance to examine the
tiple barriers to care have been identified in APIA women. A
main effects of the racial group status. The Levene's test of
recent report stated that breast cancer rates are increasing in
equality of error variances was computed to determine ho-
Asian American women, with Japanese American women
mogeneity. When equal variance was found, post hoc analy-
being the hardest hit by this change (Deapen, Liu, Perkins,
ses were completed using least significant differences
Bernstein, & Ross, 2002). Higher mortality and lower survival
(LSD). When a Levene's test was significant, indicating
rates are more evident in the APIA population compared to
unequal variance, a conservative post hoc procedure (the
Caucasian women because of the late stage of breast cancer
Tamhane T2 test) was employed to find differences between
when first diagnosed (Yi & Prows, 1996).
racial groups.
Almost 60% of people in the United States die in the hos-
pital. However, a literature review failed to locate information
that focused specifically on hospitalized APIA women with
The sample included 20,246 women (16,788 Caucasians,
breast cancer or whether their mortality rates during hospital-
1,865 African Americans, 937 Latinas, 370 Asians, 19 Native
ization differed from those of other racial groups. Data on
Americans, and 267 other) (see Table 1). The mean age was
hospitalizations of Asian women related to breast cancer are
61.23 ([SD = 14.51 years, range = 20103 years). The second
scant. Even though the Healthcare Financing Administration
sample contained 261 women (182 Caucasians, 51 African
has attempted to improve racial codes on Medicare forms,
Americans, 22 Latinas, 5 Asians, and 1 other) (see Table 2).
data on APIA women are limited. One recent study compared
Significant main effects were found between subjects in
racial and ethnic differences in hospitalization rates among
the living sample for race (F2, 20245 = 72.52, p = 0.001).
aged Medicare beneficiaries. The researchers reported that
The Levene test of equality of error variances was signifi-
hospitalization for older adult Asians was 32% lower than for
cant, indicating a lack of equal multivariate variance (F5,
their Caucasian counterparts. In addition, the risk ratio for ad-
20245 = 3.11, p = 0.008). Post hoc analysis using Tamhane's
mission to the hospital for breast cancer was 0.50 as compared
T2 test found significant differences between APIA women
to Caucasians (Eggers & Greenberg, 2000). No information
and Caucasian women (mean difference = 6.44 years, p =
was found that focused specifically on age differences at hos-
0.001) and Latinas (mean difference = 2.62, p = 0.021) (see
pitalization in women with breast cancer or on age differences
Table 3).
in women who died from breast cancer during hospitalization.
Does a difference in age exist between APIA women with
Therefore, the purpose of this study was to investigate
breast cancer who die in the hospital and women in other ra-
whether differences in age and death rates exist between hos-
cial groups who die in the hospital? Significant main effects
pitalized APIA women and women of other racial groups.
were found between subjects in the sample of people who died
during hospitalization for race (F4, 260 = 3.08, p = 0.02). Post
hoc analysis using LSD found significant differences between
APIA women and Caucasian women (mean difference =
The Health Cost and Utilization Project 1997 was a national
data set collected and maintained by the Agency for Health-
17.01 years, p = 0.01) and Latino women (mean difference =
18.89, p = 0.01) (see Table 4). APIA women were, on aver-
care Research and Quality (1997). It consisted of 7.1 million
age, the youngest to die, with a mean age of 46.2 (SD = 10.08
inpatient records from 22 states (900 hospitals) and reflected
years). On average, Asian women were 17 years younger at
hospitalization nationally. A secondary analysis was per-
formed using SPSS PC version 11.5 (SPSS Inc., Chicago,
death compared with Caucasian women, 12 years younger
compared with African American women, and almost 19
IL). A general linear model univariate analysis of variance
years younger compared with Latino women (see Table 2).
was used to determine differences.
Table 1. Women With Breast Cancer by Race Who Did Not
Eisenberg, 2000; Rees et al., 2000). This may delay treatment
Die During Hospitalization
for certain illnesses and contribute to diagnosis at advanced
stages of disease. Additional support may be found in a re-
Mean Age at
search study that explored the influence of socioeconomic and
Racial Group
cultural variables on breast cancer mortality in a sample of
540 African American women (Lannin et al., 1998). The au-
thors concluded that socioeconomic variables, combined with
African American
cultural beliefs and attitudes, contributed to subjects coming
to treatment at more advanced stages of disease.
APIAs with more advanced disease may be less likely to be
Native American
treated aggressively for their disease, thus accounting for a
higher death rate. This could have been a factor that influ-
enced the findings in the current investigation. Two studies
Note. Because of rounding, percentages do not total 100.
supported by the Agency for Healthcare Research and Qual-
ity that focused on age and race differences in the treatment
of breast cancer lend support to this conjecture. Mandelblatt
et al. (2002) found that older African American women who
were sicker, had more advanced disease, and lived in impov-
APIA women face a variety of barriers to health care that
erished neighborhoods were 48% less likely to receive recom-
may result in starting and receiving treatment later in the dis-
mended treatment consisting of mastectomy and radiation
ease course and at an older age, which contributes to increased
therapy for localized breast cancer. A study conducted by
morbidity and mortality rates (Gullatte, 1999; Hedeen &
Edge et al. (2002) found that women who were older and had
White, 1999; Ortin, 1998; Tang et al., 2000). This analysis in-
poorer functional status were less likely to undergo axillary
dicates that APIA women are among the youngest women
lymph node biopsy after breast cancer surgery.
being hospitalized for the treatment of breast cancer. This
Josyln (2002) investigated differences in treatment for
finding is supported, in part, by an annual report issued by the
women who were diagnosed with early-stage breast carci-
state of Oklahoma in 1999, which provided information on
noma and received breast conserving surgery. She reported
hospitalizations according to race (Health Care Information,
that African American women were less likely to receive fol-
1999). The average age for Asians who were hospitalized was
low-up radiation therapy in every age group except one (> 85
30.1 years compared to Caucasians ( X = 50.7 years), Native
years). Additionally, Breen, Kessler, and Brown (1996) re-
Americans ( X = 41.8 years) and African Americans ( X = 39.6
ported that African American or Hispanic women with breast
years). The Oklahoma report indicated that the hospitalization
cancer who were older and had less income and education
rate for Asians (3.6%) was lower than for Caucasians (10.1%)
were more likely to receive less than standard care. Although
and African Americans (9.8%). In addition, the percentage of
none of these reports included APIA women, the fact that
Asians who died during hospitalization was 1.6%, which was
minority women were less likely to undergo standard treat-
lower than the rates reported for Caucasians, Native Ameri-
ment options is worthy of attention.
cans, and African Americans (2.8%, 2.9%, and 2.3%, respec-
The current sample was drawn from a national data set con-
tively). The 1.9% death rate found in the current study is simi-
sisting of 7.1 million inpatient records reflecting hospitalization
lar to that found in the Oklahoma report. Strzelczyk and
from more than 20 states. However, the number of women dy-
Dignan (2002) analyzed data collected by the Colorado Mam-
ing in hospitals from breast cancer indicates a uniformly rare
mography project to evaluate whether a diverse sample of
event across all races (n = 261). Therefore, the findings in the
women adhered to follow-up recommendations after mam-
current study of those who died during hospitalization must be
mography. Although the number of subjects was large (N =
viewed cautiously. The low numbers of hospitalized deaths
167,232), only 1.6% of the sample was identified as Asian.
with a breast cancer diagnosis may result from unstudied
Clearly, recruiting Asian women for research on breast can-
nonpatient-related variables. However, despite the low number
cer screening is a challenge.
of APIA subjects, the strength of the study design makes the
Additional support for the younger age of the APIA women
results plausible.
in the current study is found in research conducted by Lin,
Phan, and Lin (2002) on Vietnamese women living in Califor-
nia. The researchers compared age, stage, and histologic grade
of tumor and found that the women in the sample were
Table 2. Women With Breast Cancer Who Died During
younger at diagnosis ( X = 51.0 years) than other minority
groups. Almost half of the Asian women were diagnosed be-
fore the age of 50 years.
Mean Age
Racial Group
at Death
Information about staging of breast cancer for the women
in this sample was not available for analysis. Perhaps Asians
in the sample were coming to treatment with more advanced
African American
disease and, therefore, a reduced chance of long-term survival.
Some support exists for this conjecture, because the APIA
group in the current study died at a mean age of 46.2 (SD =
10.08 years). The literature suggests that Asians are more
likely to seek alternative care for illness prior to seeking care
Note. Because of rounding, percentages do not total 100.
from healthcare professionals (Lee, Lin, Wrensch, Adler, &
Table 3. Comparison of Mean Age Differences of Asian Pacific Islander American Women With Women of Other Races
Who Did Not Die During Hospitalization
95% Confidence Interval for Differencea
Mean Difference
Standard Error
Lower Boundary
Upper Boundary
African American
Native American
Adjustment for multiple comparisons: least significant
Women in the APIA group made up 1.9% of the sample of
estimate the threat of breast cancer developing in APIA
women with breast cancer who died during hospitalization but
women. This misperception may have a negative effect on
health teaching. As a consequence, APIA women may not
did not accurately reflect the percentage of APIA women in
receive adequate and culturally appropriate information on
the United States as a whole. This reflects a report by Eggers
and Greenberg (2000) that indicated that hospitalizations for
screening mammography and clinical breast examination dur-
ing routine care. Prospective studies are needed to follow this
older adult Asians were significantly lower than for older
adult Caucasians. The women in the current study were not
population of women to identify risk factors associated with
older dults, but a pattern of fewer hospitalizations for Asians
later diagnosis. Descriptive studies also are recommended to
determine why APIAs are not using screening programs.
is suggested. Racial disparities in health care must be ad-
Interventional studies to examine the impact of ethnically sen-
dressed. As the population of APIAs grows, additional data
sitive care are warranted as well.
for analysis will become available.
Nursing Implications
Cultural awareness is critical when discussing methods for
Secondary analyses of data sets have disadvantages (Ka-
prevention and early detection of breast cancer with minority
gawa-Singer, 1995). In the current study, the number of APIA
women. Nurses should have an understanding of the barriers
women who died during hospitalization was low, which made
to receiving care and act to minimize them. Heeden and White
drawing meaningful conclusions difficult. The researchers
(1999) reported that first-generation Asian American women
were limited to the variables provided in the data itself. For
have a higher incidence of larger tumors at diagnosis com-
example, the data set did not include biologic, societal, famil-
pared to second- and third-generation Asian Americans. This
ial, or environmental data that may have helped to explain
could indicate that healthcare professionals are making strides
differences in the findings.
providing information to acculturated second- and third-gen-
"Databases must be disaggregated among different APIA
eration APIA women. Distrust of health professionals and
women's groups to allow for the diversity of the population
Western style of medical care may explain limited access to
and cultural reasons for variances in breast cancer incidence
care by APIAs (Snyder, Cunningham, Nakazono, & Hays,
and mortality" (Ortin, 1998, p. 28). The findings in the current
2000). Targeting new immigrants is a priority for those who
study may be a factor of unequal sample size as determined by
screen and educate women about breast cancer detection and
the numbers included in each racial group, thereby limiting in-
terpretation of results.
Statistically, APIA women have lower breast cancer inci-
dence than their Caucasian American counterparts. This fact,
along with cultural influences and barriers to care, may help
to minimize the perception of breast cancer as a major health
This analysis of a national data set indicates that APIA
threat to this population. Healthcare professionals may under-
women are among the youngest women being hospitalized for
Table 4. Comparison of Mean Age Differences of Asian Pacific Islander American Women With Women of Other Races
Who Died During Hospitalization
95% Confidence Interval for Differencea
Mean Difference
Standard Error
Lower Boundary
Upper Boundary
African American
Adjustment for multiple comparisons: least significant
the treatment of breast cancer. The age of APIA women with
death rate found in the current study could be a bias regarding
breast cancer who died in the hospital was significantly differ-
how APIA women come to the hospital (i.e., later and sicker).
ent than that of other racial groups. However, results should be
viewed with caution because the sample did not reflect the per-
Author Contact: Carolee Polek, PhD, RN, can be reached at
centage of APIA women in the U.S. population. The 1.9%
cpolek@udel.edu, with copy to editor at rose_mary@earthlink.net.
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