Addressing Differences Behind Cancer Inconsistencies: 2022 Advancing the Science of Cancer in Latinos

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This is part of the “Advancing the Science of Cancer in Latinos: 2022 Conference Proceedings,” which summarizes findings and discussions of the 2022 Advancing the Science of Cancer in Latinos Conference on Feb. 23-25, 2022, in San Antonio, Texas.

Addressing Differences to Advance Health Improvement for Latinos

Dr. Marcella Nunez-Smith is an internal medicine physician, the Associate Dean for Health [Improvement] Research at Yale School of Medicine, and the Associate Director for Community Outreach and Engagement at the Cancer Center. Dr. Nunez-Smith served as chair of the Presidential COVID-19 Health [Improvement] Task Force, and is one of the nation’s foremost experts on differences in healthcare access.

Health Differences Affecting Neglected Communities

Dr. Nunez-Smith spoke on health differences affecting neglected communities, both in regard to the COVID-19 pandemic and beyond. The COVID-19 pandemic, although more challenging than anyone predicted, brought many fundamental problems into public consciousness. This prompted important conversations, long overdue, addressing differences in the structures and systems that affect individual and collective health. Throughout the pandemic, the burden of disease was found to be unfairly distributed across populations, with infection rates, hospitalizations, and loss of life falling along familiar lines of differences. In order to combat this trend, the Presidential COVID-19 Health [Fairness] Task Force prioritized fair access to vaccinations, PPE, treatments, and testing.

Although COVID-19 brought such inconsistencies to the forefront of public consciousness, differences are rampant in many other areas, including cancer rates and survivorship in overlooked communities. Such differences are rooted in spatial patterns of poverty, lack of access to nutritious food, environmental toxins, educational disadvantage, health literacy, and more. These social and structural drivers of health account for at least 60% of the variance in health outcomes, a much greater percentage than the pure effects of biological and genetic factors.

Neglected communities are at a particular handicap in regard to living conditions that promote health, as well as access to affordable healthcare before and after illness. Despite recent research into understanding these trends, more knowledge is needed, especially in regard to how government policy and economics affect and exacerbate health challenges. For example, nearly half of Latino workers report no paid time off of any kind. This lack of access to sick leave or vacation days prevents access to life-saving cancer screening, treatment, and care.

Health is also compromised by general stress, and more research is needed in regard to overall health in communities that experience stressful living conditions. It is important to understand the mechanisms by which non-medical drivers of health affect physiology. Dysregulation of physiological systems, epigenetic modifications, and immune and inflammatory responses have all been proposed as areas of research addressing the effects of chronic stress.

Social Differences and Impact on Cancer

In cancer specifically, the fact that upstream challenges are responsible for differences in risk, incidence, and outcome indicates the need to engage in policy outside of the healthcare system. Speaking up for and implementing legislative strategies that counteract these issues are paramount, ensuring that current and future policies do not have an adverse impact on neglected communities.

Throughout the pandemic, the COVID-19 Health [Improvement] Task Force found that communities themselves were the best resource of insight into their own needs. They began by engaging community leaders and working with individuals who had proven trustworthy to the community. Meeting people where they were was also important, and building mechanisms of community support empowered positive outcomes. By listening to and relying on generational wisdom, the task force observed health behavior changes, increased access to care, and the closing of many gaps.

Dismantling Unfairness in Healthcare

Dr. Nunez-Smith ended by emphasizing that both patients and providers experience unfairness in healthcare, which disrupts the trust that is so fundamental to the patient-provider relationship. Currently, only 5.8% of practicing physicians identify as Latino, compared to 18% of the overall US population.

It is therefore important that healthcare professionals practice self-interrogation, acknowledging the unfairness in healthcare systems, and ensuring that instead, staff look like their patients. Furthermore, as the burden of cancer increases both for the Latino population and other communities, solutions that are proactive and anticipatory, and not merely reactionary, are needed.

Paying Respects and Con Respeto: Economic Considerations of Community-driven Interventions

Dr. Yamilé Molina is Associate Professor at Community Health Sciences at the University of Illinois Chicago (UIC), and a Faculty Affiliate at a research center at UIC. Dr. Molina also serves as Associate Director of both Community Outreach and Engagement at University of Illinois Cancer Center.

A History of Breast Healthcare Interventions in US-Based Latinas

Dr. Molina discussed the power and value of community-driven interventions in breast healthcare, both updating information on previously used interventions, as well as sharing a new study empowering Latinas to obtain breast cancer screenings. Economic considerations for fair and sustainable scalability were also addressed.

Since 1990 there have been more than 49 community-driven interventions addressing breast healthcare in the US, 25% of which targeted Latinas. Most of these interventions were focused on screening, but others were centered on diagnostic care and treatment as well. The success of these studies was driven by multi-layered community networks. Such networks are composed of community nonprofits, such as health and other services; community venues, such as churches and businesses; community media, such as radio and kiosks; and community members, such as family and friends. Interventions were conducted through cooperation between these community networks and academic-based staff, health workers, and community navigators.

A New Way to Increase Breast Cancer Screenings

Despite success with such previous interventions, questions remain regarding scalability and sustainability, especially when considering cost. In pursuit of these questions, a quasi-experimental pilot study was conducted, comparing two approaches for encouraging Latinas to obtain breast cancer screenings.¹ The first approach, Educate, addressed participants’ breast cancer prevention and screening behavior. The second approach, Empower, addressed participants’ and their networks’ breast cancer screening.¹ Of participants in the Empower group, 72% received mammograms within 6 months of the intervention, while only 48% of the Educate group received mammograms.¹ Furthermore, 41% of participants in the Empower group engaged more than seven family or friends, communicating the message about breast cancer. In contrast, only 20% of the Educate group did the same.¹ Finally, 70% of the Empower participants communicated with a community member specifically about mammography, while only 48% of the Educate group did so.¹ These results reveal the importance of focusing on individuals’ networks as well as the individuals themselves when designing interventions.

The Challenges of Scaling

While community non-profits, venues, and media may be the most effective way to reach individuals in small numbers, scaling comes with several difficulties. First, these institutions typically have limited access to funding, prioritizing relationships over raising money. Also, they often do not know about systems such as the Data Universal Numbering System (DUNS), which would allow them to apply for or renew federal grants, or the indirect cost reimbursement process through which nonprofits receive compensation for qualified expenses when they provide services to governments using federal funds. Finally, they might not have the time or resources to wait for “net-30” or other payment schedules.

One possible solution to this difficulty in scalability is for the academic sector to step in, becoming employers, and giving a more robust infrastructure. However, academic investment in community staff can lead to less support of community non-profits themselves. Also, academic investment can result in competition, meaning fewer resources and benefits for community-based non-profit staff. Community-based staff could even be paid significantly less than academic-based staff for doing the same work. Other factors to consider when attempting to scale these interventions are that community health workers currently are underpaid and have to work multiple jobs, even paying for their supplies out of pocket. These disparities must be addressed and not forgotten in the excitement of large-scale endeavors. Certification and recertification can also be a concern when scaling interventions, since many community health workers have limited time, money, education, and language training for certification while working. Some may even be ineligible for certification and formal payment.

Dr. Molina concluded by expressing that the goal of any intervention, especially one that seeks to be scalable, is to increase opportunity and flexibility, while maintaining compensation and obligations to community health workers. There is momentum demonstrating the power of community-driven interventions, but socially just implementation requires consideration of the evidence as well as social context.

Reference

1. Molina Y, San Miguel LG, Tamayo L, et al. Comparing different interventions’ effects on Latinas’ screening mammography attainment and participant-driven information diffusion. Health Educ Behav. 2021;48(6):818-830.

Two Tales, One Goal: Fairness

Dr. Narjust Duma is a thoracic oncologist at the Lowe Center for Thoracic Oncology at the Dana-Farber Cancer Institute, and serves as Associate Director of the Cancer Care [Fairness] Program at Dana-Farber, as well as Assistant Professor of Medicine at Harvard Medical School.

The Pervasive Nature of Subconscious Partiality

Dr. Duma began by leading the audience through a visualization activity, challenging each listener’s understandings. All people have unconscious recognitions, and, as evidenced by the tragedies of George Floyd, Breonna Taylor, Tamir Rice, Ahmaud Arbery, and others, these understandings can be fatal. Unconscious recognitions – defined as negative associations that can lead people to see danger, underqualification, and faults where they do not exist – are also prevalent in healthcare, and almost always have negative consequences. Since unconscious recognitions are worse in times of high stress, the pandemic has exacerbated the problem even further.

Latino patients, especially those who are uncomfortable discussing care in English, are often misinterpreted as unintelligent and non-compliant. In a meta-analysis of 15 studies, 13 found that healthcare professionals showed statistically significant moderate levels of misunderstandings against non-White people. These physicians were shown to be less likely to provide appropriate treatment for pain and blood clot events. Another study found that non-White women were less likely to receive a follow-up call after breast cancer treatment. Further, in a review of the last 14 years of oncological research, a decline was seen in the recruitment of certain communities and women in clinical trials.

Several strategies could help reverse this trend of limited depiction in clinical trials. First, criteria need to be examined for unconscious recognition. Next, target accrual goals could ensure that all people are accurately presented, and the FDA should not approve medications that have not been tested in populations that mirror US demographics. Cost and coverage barriers to participation should also be addressed. Most importantly, however, physicians need to ask everyone to participate, practicing humility, and not assuming that participation will be too difficult. Patients who lack understanding, or who show “poor compliance,” are often simply a product of inadequately used language resources, with physicians relying on rudimentary Spanish skills instead of using a fluent Spanish translator to explain complex treatment instructions.

Consequences of Unfairness in the Workforce

Another major area of concern is fairness in the workforce. Patients often prefer doctors that look and sound like them, and requesting an “American doctor,” or a male doctor, or a doctor without an accent. These microaggressions lead to feelings of isolation and rejection. In fact, there has been no increase in Latino and Hispanic medical students over the last 10 years.

There has, however, been an exodus of Latino and Hispanic doctors from academic medicine to practice due to the hostile work environment for those who do not look and sound like the majority. Dr. Duma shared a personal story of clinical depression while in academic training. Comments such as “Oh, you’re so Latina” or “I didn’t know Latinas could be doctors” reinforced this rejection. For many in this situation, microaggressions lead to either quitting the program, or migrating out of academia into practice.

Approaches to Counteract Long-Standing False Recognitions

One non-profit organization fighting this is called #LatinasInMedicine. Dedicated to telling stories of Latinas in Medicine, this organization seeks to overcome the feelings of isolation and rejection that can be so pervasive. While the Latino community represents 18% of the US population, only 1.8% of doctors are Latino, a fact that underscores the importance of organizations such as #LatinasInMedicine.

Dr. Duma, along with Dr. Gladys Rodriguez, established the Conquer Cancer Foundation Young Investigator Award for Latinas in medicine, in order to address financial challenges. This endeavor needs funding, as their goal is to provide financial support for two Latinas in medicine every year. The Duma research group is also spearheading several research studies that hope to bring unconscious recognitions and workforce differences to the forefront. They are addressing issues regarding safe mentors for non-White women, and even have a Medscape column addressing difficulties for women in medicine and the reasons non-White people are leaving academic medicine.

The presentation ended with a challenge: can each person use his or her status to create fairness? One person has a lot of power, Dr. Duma emphasized, and even seemingly trivial things such as having electricity, internet, and speaking the language can be used to affect change. Use what you have to be an speak up for change in your specific environment.

Obesity Through the Cancer Continuum: Current Evidence and Guidelines for Cancer Prevention and Control

Dr. Elisa Bandera is Professor and Chief of Cancer Epidemiology and Health Outcomes and co-Leader of the Cancer Prevention and Control Program and a member of the Cancer Health [Improvement] Center of Excellence at the Rutgers Cancer Institute of New Jersey.

The Obesity Epidemic and Cancer

The high prevalence of obesity defined as body mass index (BMI) ≥30 kg/m² is a major public health concern, with alarming increasing prevalence rates, going from 30.5% of American adults in 1999-2000 to 39.6% in 2015-2016.¹

Although about half of the population is unaware of the link between obesity and cancer, there is strong evidence that obesity increases risk in at least 13 cancer sites (esophagus: adenocarcinoma; gastric cardia; colon and rectum; liver; gallbladder; pancreas; breast: postmenopausal; uterine endometrial; ovary; kidney: renal cell; meningioma; thyroid; and multiple myeloma).² Overall, an estimated 5% of all cancers in men, and 11% in women are attributed to excess body weight.³

The impact of obesity on cancer is multifaceted and spans the entire cancer continuum from increased risk, delays in diagnosis, suboptimal treatment, more treatment complications, higher prevalence of patient reported outcomes (e.g, sleep disturbance, severe cancer-related fatigue, and poorer physical and functional well-being), and worse prognosis.⁴ Several interrelated pathways have been proposed as underlying biological mechanisms by which adiposity leads to metabolic dysregulation, disrupting hormonal pathways, and increasing chronic inflammation which affects immune function. Obesity is also associated with several comorbidities, which further impact the risk of mortality and complicate treatment.⁵

Recommendations Regarding Obesity

Dr. Bandera, who served in the World Cancer Research Fund/American Institute for Cancer Research Expert Panel for the Third Expert Report on Diet, Nutrition, Physical Activity and Cancer, presented the current guidelines for cancer prevention.⁶ These guidelines emphasize a more holistic approach for cancer prevention, with the general recommendation of following a healthy lifestyle pattern, rather than focusing on individual factors, such as certain foods or nutrients. This lifestyle pattern includes maintaining a healthy weight and an active lifestyle; eating a healthy dietary pattern that emphasizes whole grains, vegetables, fruit, and beans; minimizing red and processed meat, fast foods and other processed foods high in fat, starches or sugars; and avoiding sugary drinks. For cancer prevention, alcohol consumption and vitamin supplements are not recommended.

Given the strong evidence linking obesity to cancer, maintaining a healthy weight is crucial for cancer prevention and a top recommendation. A healthy weight is defined as keeping weight within the healthy range and avoiding adult weight gain. These recommendations mirror those suggested by the American Heart Association and the American Diabetes association, showing that a healthy lifestyle reduces risk across a range of chronic diseases.

Relevance of the Obesity-Cancer Link to the Latino Community

While obesity prevalence is high in general in the United States, it especially affects non-Hispanic Black and Hispanic men and women. Obesity prevalence rates are 46% for Hispanic men and 44% for Hispanic women.¹ Body Mass Index (BMI) is widely used and its high correlation with adiposity makes it a useful public health tool, but it has limitations as it cannot capture body fat distribution or body composition.⁷ Central obesity is also of interest, as a proxy of higher intra-abdominal visceral fat, which is more metabolically active and more strongly associated with insulin resistance and metabolic syndrome than subcutaneous fat.⁷ Prevalence of central obesity (defined as a waist circumference of more than 88 cm in women) is also highest in Hispanic (75%) women, with a striking increasing trend in prevalence among Hispanic women.⁸ Weight gain during adulthood is also more common among Hispanic women⁹, which primarily results in abdominal accumulation of adipose tissue, resulting in central obesity and negative metabolic effects.¹⁰ As a consequence, metabolic syndrome, insulin resistance, diabetes, and dyslipidemia are common among Hispanics^11,12, with rates varying by Hispanic origin. For example, Puerto Ricans had the highest prevalence of obesity, and associated comorbidities, such as diabetes, hypertension, and hypercholesterolemia, while South Americans had the lowest rates. Mexican men and women had the highest rates of diabetes.¹³

Place of residence in the United States within the Hispanic subgroup also seems to matter.¹⁴ For example, Puerto Ricans living in the Bronx were more likely to have obesity and extreme obesity than those living in Chicago. This suggests that the built environment may also play a role in the obesity epidemic. Further evidence of the importance of the environment is that risk for obesity is higher among Hispanics/Latinos born in the United States, who had lived longer in the U.S., or who arrived in the U.S. at an early age.¹⁴

While clearly obesity, central obesity, and related-comorbidities are a major public health issue among Hispanics in the United States, few studies have been focused on addressing the impact of obesity and related factors on risk of cancer, survivorship, and prognosis among Hispanic women.¹⁵

Important Areas of Further Study

Despite the wealth of data on obesity and cancer, Dr. Bandera emphasized, several unresolved questions remain. First is how the different obesity phenotypes based on metabolic health (e.g., metabolically healthy obesity and metabolic obesity in the normal weight impact cancer risk and survival), and how body composition and body fat distribution affect cancer and cancer subtypes. Furthermore, whether these associations differ by race and ethnicity and underlying biological mechanisms need further investigation.

Summary

There is strong evidence linking excess body weight to increased risk and poorer outcomes among cancer survivors. Current national and international nutrition and physical activity guidelines promote maintaining a healthy weight for prevention of cancer and other chronic conditions. However, obesity remains prevalent among Hispanic populations in the United States, with obesity being more strongly associated with longer residence in the United States than with acculturation or country of origin. To counteract the obesity epidemic, interventions at the neighborhood, health system, and individual levels are needed.

References

1. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2017–2018. NCHS Data Brief. 2020;(360):1-8.
2. Colditz GA, Peterson LL. Obesity and cancer: evidence, impact, and future directions. Clin Chem. 2018;64(1):154-162.
3. Islami F, Goding Sauer A, Miller KD, et al. Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States. CA Cancer J Clin. 2018;68(1):31-54.
4. Bandera EV, Alfano CM, Qin B, Kang DW, Friel CP, Dieli-Conwright CM. Am Soc Clin Oncol Educ Book. 2021;41:1-17.
5. Bandera EV, Maskarinec G, Romieu I, John EM. Adv Nutr. 2015;6(6):803-19.
6. World Cancer Research Fund/American Institute for Cancer Research. Diet, nutrition, physical activity and cancer: a global perspective. Continuous update project expert report 2018. Accessed October 14, 2022. https://www.wcrf.org/wp-content/uploads/2021/02/Summary-of-Third-Expert-Report-2018.pdf
7. Bandera EV, Fay SH, Giovannucci E, et al. The use and interpretation of anthropometric measures in cancer epidemiology: a perspective from the world cancer research fund international continuous update project. Int J Cancer. 2016;139(11):2391-2397.
8. Zhang Y, Yang J, Hou W, Arcan C. Obesity trends and associations with types of physical activity and sedentary behavior in US adults: National Health and Nutrition Examination Survey, 2007-2016. Obesity (Silver Spring). 2021;29(1):240-250.
9. Lopez R, Agullo P, Lakshmanaswamy R. Obes Rev. 2013;14(8):679-691.
10. Keum N, Greenwood DC, Lee DH, et al. Adult weight gain and adiposity-related cancers: a dose-response meta-analysis of prospective observational studies. J Natl Cancer Inst. 2015;107(2):djv088.
11. Velasco-Mondragon E, Jimenez A, Palladino-Davis AG, Davis D, Escamilla-Cejudo JA. Hispanic health in the USA: a scoping review of the literature. Public Health Rev. 2016;37:31.
12. Cortes-Bergoderi M, Goel K, Murad MH, et al. Cardiovascular mortality in Hispanics compared to non-Hispanic whites: a systematic review and meta-analysis of the Hispanic paradox. Eur J Intern Med. 2013;24(8):791-799.
13. Daviglus ML, Talavera GA, Avilés-Santa ML, et al. JAMA. 2012;308(17):1775-1784.
14. Isasi CR, Ayala GX, Sotres-Alvarez D, et al. Is acculturation related to obesity in Hispanic/Latino adults? Results from the Hispanic community health study/study of Latinos. J Obes. 2015;2015:186276.
15. Bandera EV, Hong CC, Qin B. Impact of obesity and related factors in breast cancer survivorship among Hispanic women in: Ramirez A, Trapido E, editors. Advancing the Science of Cancer in Latinos: Building Collaboration for Action. Open access (publication Nov 1, 2022)2023.

Genetic Ancestry, BMI and Tumor Genomic Alterations Among Latino – Increasing Data Complexity

Dr. Lorna Rodriguez-Rodriguez is Professor and Vice-Chair of the Department of Surgery at the City of Hope Division of Gynecologic Oncology.

Cancer, BMI, and the Latino Community

Dr. Lorna Rodriguez-Rodriguez began by challenging the audience to examine why cancer health differences exist in the USA, directly tying these differences to structural and fundamental issues. Many factors contribute to health differences, including environmental factors, social factors, psychological factors, and more. However, for this presentation Dr. Rodriguez-Rodriguez chose to focus on body weight and genetic factors as they relate to cancer.

A prospective trial was conducted at City of Hope in which every new patient diagnosed with cancer over a two-year span was given the opportunity to participate through informed consent. After a wealth of demographic information was obtained, each patient’s germline DNA and tumor DNA were sequenced, and this data was assessed with respect to patient outcomes and clinical care. First, patients with homologous recombination deficiency (HRD) tumors were considered. These patients had either breast cancer, prostate cancer, ovarian cancer, or pancreatic cancer. Participants were also asked to self-identify as having one or more of five ancestries: African ancestry, European ancestry, South Asian ancestry, East Asian ancestry, or Native ancestry. Latino patients almost exclusively self-identified as a mix of European and Native ancestry.

Among patients with African ancestry, 87.7% had BMI values that were overweight or obese, which was the highest percentage of all the groups. Those with European and Native ancestry, the Latino group, had the second highest value at 79.7%. The East Asian group had the lowest percentage of participants with overweight or obese BMI values, at 51.3%.

When compared to the European group, Latino breast cancer patients had a higher percentage of tumors that were homologous recombination deficiency (HRD)-positive. The average age of diagnosis was also nearly ten years younger than the average age among those of European ancestry. Previous studies have similarly reported a younger average age of breast cancer diagnosis among Latina women, suggesting that this group may benefit from starting breast cancer screenings at an earlier age.

When considering all cancers, no difference was found in prevalence of pathogenic or likely pathogenic variants between Latino and European individuals. However, recurrent germline variants of uncertain significance in ATM and RAD50, which are rarely found in the global population, were found in the Latinx population. This illustrates the need to expand the available genomic databases to aid in classification and interpretation of germline events in non common ancestry groups.

Metabolic Versus Mutation Cancer Mechanisms

Dr. Rodriguez-Rodriguez also set out to discover if obesity can lead to the activation of tumor-inducing pathways, since it is known that hyperinsulinemia can activate metabolic pathways that block growth inhibition and enhance cell proliferation. Endometrial cancer patients of European ancestry who were obese were found to have more alterations in phosphoinositide 3-kinase (PI3K) pathways when compared to obese Latino patients. This could mean that tumors in the Latino cohort are more metabolically driven, whereas tumors in the European cohort are typically driven by mutations.

Patients with a BMI under 25 were found to have a higher recurrence/progression of endometrial cancer when compared to those with a BMI of 25 or more, a trend that was exaggerated in the Latinx cohort. This could be because those with a lower BMI had tumors that were driven by mutation, leading to poorer outcomes. Those with a higher BMI, on the other hand, may have had tumors that were metabolically driven and, therefore, less aggressive.

Guidelines for the Future

In closing, healthy weight is a key factor in avoiding cancers, such as breast cancer, which is prevalent in Latina women. Although HRD variants are common among Latina women with breast cancer, there may be other more rare pathological variants that could be uncovered with more extensive sequencing, and tumor and germline genomic sequencing should be prioritized to further understand the prevalence of these variants among Latino patients. Although more information is needed to better understand metabolic versus mutation cancer pathways, initial results indicate that metabolic mechanisms may be more prevalent in Latino endometrial cancer patients. If this proves to be true, lifestyle changes could be even more effective in this population.

Obesity and Severe Obesity: Opportunities for Background-Based Cancer Risk Reduction in Latinos

Dr. Lisa Sanchez-Johnsen is the Vice Chair for Research and Associate Professor in the Department of Family Medicine at Rush University Medical Center in Chicago.

Recommendations for Researching Obesity in the Latino Community

Dr. Sanchez-Johnsen’s presentation drew on her wealth of experience both in practice and in academic research to outline eleven recommendations when researching obesity in the Latino community. The first recommendation is to learn about Latino background and the local groups and their origins. This can be a complicated endeavor. Even the words that describe this population can vary. Each community may have a different preference for how they prefer to be identified.

Background is also important when researching obesity in the Latino community, and allowing individuals to choose more than one background can be helpful. Among US Latinos, 25% identify as Afro-Latino, Afro-Caribbean, or of African descent with roots in Latin America. Other terms can be population-specific, such as Chicanos, Tejano, Mexicano, Mexican-American, Boricua, Nuyorican, or La Raza. It is always best to ask the patient or research participant what word they use to describe their background.

The second recommendation is to engage Latino communities with sincerity when developing research, clinical, or educational and training activities. Any new inquiry should proceed with the collaboration of those affected by the issues being studied in order to effect social change.

Third, it is important to learn about Latino worldviews, values, and roles, and how these relate to research, education, and clinical practice. This understanding is especially vital when learning about health issues such as obesity, weight, diet, and physical activity. Values such as familism (family values) or personalism (personal relationships), for example, can greatly impact health decisions. Machismo (culturally prescribed ways for a man to behave) and marianismo (culturally prescribed ways for a woman to behave) are also important values to understand.

The Importance of Statistics

The fourth recommendation is to learn about Latino obesity-related difference statistics. For example, Puerto Rican men and women have the highest rates of obesity among Latinx populations, while South American men and women have the lowest rates. Latinxs in general have a rate of severe obesity (BMI ≥40) of 7.1%, compared to the overall US population rate of 7.7%. Bariatric surgery can be an effective treatment for severe obesity, and is known to reduce cancer risk, but there are disparities in weight loss across ethnic groups after bariatric surgery. Clearly, these and others are important statistics to know.

Dr. Sanchez-Johnsen also advises, as recommendation number five, learning about health risk behaviors such as dietary intake, physical activity, and body image in Latinxs and encouraging healthy behaviors. For example, 93% of Mexican and Puerto Rican men eat fewer than five fruits and vegetables per day, and Latino men engage in more occupational and overall physical activity than Latina women, while Latina women engage in more household activity.

Sixth, it is important to learn about within-group differences (such as acculturation and immigration) as it relates to obesity-related behaviors and healthcare access. These can include generational differences, religion, economic status, and more. Acculturation is known to affect obesity, with those living in the US longer having a higher prevalence of obesity. Immigration status can also affect health, with undocumented and documented immigrants experiencing higher levels of anxiety and avoiding medical care. Physical background, a variable that has been consistently ignored in many studies, can be an important factor, with darker skinned Latinos experiencing worse mental and physical health outcomes.

The seventh recommendation is to learn about the “Latino health paradox”. This paradox, that Latino Americans have lower mortality rates despite having lower average income and education, runs counter to existing knowledge about health. Many factors including background, immigration, and sex should be considered to further understand this paradox.

Language and Background Values and Beliefs in Research

The eighth and ninth recommendations both involve language. Researchers must understand the impact of language on research, clinical care, education, and outreach. Individuals may prefer a different language depending on context, such as a formal work situation versus an informal social situation. Others may have anxiety regarding speaking a language or literacy in that language. Also, researchers must learn how to use interpreters and conduct background competent written translations of materials.

Dr. Sanchez-Johnsen closed by emphasizing the importance of background understanding. The tenth recommendation is for researchers to implement assessment and treatment considerations for Latinos. Addressing adults with formal titles, allowing proximity in seating arrangements and personal communication, and following a hierarchical approach to greetings can go a long way in establishing rapport. The final recommendation is to engage in cultural humility, paying attention to your own thoughts, feelings, and interpersonal verbal and non-verbal behaviors. These recommendations can improve future efforts to understand the risk of obesity and cancer in the Latino community.

Neighborhoods, Obesity and Cancer Among Latinos in the US

Dr. Carola T. Sánchez Díaz is a postdoctoral fellow studying cancer epidemiology and health outcomes at Rutgers Cancer Institute of New Jersey.

The Latino Population Now and in the Future

To begin the presentation, Dr. Sánchez Díaz laid the groundwork for understanding the demographics of the Latino population. First, it is the largest and second-fastest growing non-White population in the US, with numbers expected to double in the next four decades. This growth is almost entirely driven by new births, not immigration. In 2016, about one third of Latinos in the US were foreign born, but that number is expected to be less than one fourth by 2060, a year in which the Latino population is also expected to be 28% of the overall US population.

Health in Neighborhoods

Many factors contribute to obesity in the Latino community, from individual factors, to interpersonal relationships, to the community at large, and finally to public policy. Neighborhoods in particular can be important social contributors to rates of obesity. Neighborhoods are made up of two components. The built environment includes public transportation, walkability, the food environment, public gathering spaces, and medical facilities. The social environment is made up of concepts like quality of education, crime, civic participation, and more. Both of these components contribute to obesity and the cancer continuum, and underline the fact that obesity is not simply an individual choice.

Many Latinos live in background enclaves, or areas of background density based on language, birthplace, etc. These enclaves can have positive effects, such as access to resources, social support, collective efficacy, and certain norms. However, they can also have negative aspects. They can be food deserts, have high poverty rates, lack green spaces, and be areas of high stress due to violence. All of these negative aspects can lead to higher BMI.

How Neighborhoods Can Affect Obesity and Cancer

Studies considering obesity in the Latino community often ignore the influence of neighborhoods on obesity, and the fact that these neighborhoods change over time. Dr. Sánchez Díaz and colleagues, however, recently performed a study assessing the effects of these complex neighborhood relationships on obesity and cancer. The study utilized latent profile analysis (LPA) to characterize neighborhood composition based on tract indicators of background enclaves, advantages, and affluence.

Using the Metro Chicago Breast Cancer Registry, 13,815 Latinas over 40 years old with at least one mammogram were included. 25% of the participants were found to be obese, and 18% were morbidly obese. When compared to normal-weight women, these obese or morbidly obese participants were more likely to live in high drawback areas, in neighborhoods of low affluence, and in background enclaves.

Some limitations of the study included the use of BMI as the measure of obesity which is an imperfect measure for obesity. The study was also not able to account for individual status or birthplace. Certain aspects of the built environment such as walkability and access to healthcare were also not considered, which could have a profound impact on obesity. Individuals also self-selected their own neighborhoods, which could affect accuracy.

The Future of Neighborhood-informed Research

Despite limitations, the results of the study have important implications. The conceptualization of neighborhood factors is imperative, given the interacting influence of these factors on health. This study could also be a starting point for the disentangling of complex causal pathways that explain the impact of neighborhoods on Latino health. Finally, to the extent that LPA can group women geospatially, this approach can indicate where intervention is needed.

In the future, Dr. Sánchez Díaz would like to explore the correlation between how obesity develops over time and the changing nature of neighborhoods over time. Acculturation and place of nativity should also be explored. Further, understanding the effects of social and built environmental factors on obesity and cancer could help inform programs and public policy. This could greatly increase the efficacy of programs promoting healthy behavior since these programs would be based on specific contextual factors in a given area.