Cumulative Incidence Rates of Breast Cancer by Age for Filipinos and Chamorros in Guam.

Breast cancer is the second leading cause of cancer-related death among women on Guam and Hawai'i. Breast cancer incidence rates are described here for the multiethnic population in Guam, a United States (US) Pacific island territory, and compared to Hawai'i and other US populations, to understand the risk by age and race/ethnic group in this understudied group. The study included all breast cancer cases (n=576) reported to the Guam Cancer Registry, all breast cancer cases (n=8345) reported to the Hawai'i Tumor Registry and all breast cancer cases (n=678,637) reported to the Surveillance, Epidemiology, and End Results program from 2000 to 2009. Cumulative incidence rates by age were calculated for two time periods: 2000-2004 and 2005-2009. Differences were seen in cumulative incidence rates by age, ethnicity, and place of residence. Cumulative incidence rates by age 40 were the highest (0.7%) among Filipinos in Guam but, after age 40, the rates for Chamorros (indigenous Pacific Islanders of Guam) increased rapidly. The lifetime cumulative incidence rates were the highest for Chamorros in Guam (15.3%), close to the US rate (15.5%). Results were similar for 2005-2009. Women in Guam are at high risk for breast cancer, with the indigenous Chamorros having the highest risk, and the most prevalent Asian group of Filipinos, having a younger age at diagnosis. These patterns are similar to the comparable Pacific Islander and Filipino populations in Hawai'i and the US generally.

Examining the Influence of Cultural Immersion on Willingness to Try Fruits and Vegetables among Children in Guam: The Traditions Pilot Study.

This pilot study examined the influence of cultural immersion on willingness to try fruits and vegetables (FV) among children 3-12 years old in three summer camps in Guam with different cultural exposure levels: cultural immersion camp (CIC), high exposure; university day camp (UDC), moderate exposure; and recreational sports camp (RSC), zero exposure. Children, ages 3-12 years old for CIC and UDC and 5-12 years old for RSC, participated: CIC (n = 47), UDC (n = 23), and RSC (n = 33). Children's willingness to try FV was assessed with the Adapted WillTry tool before and after each program. Whole FV intakes were assessed concurrently using the mobile food record in CIC and UDC. Using multivariate regression, WillTry post-assessment outcomes were modeled adjusting for pre-assessment, child characteristics, exposure, and parent cultural affiliation. Unique to the Adapted WillTry tool are three FV scales, local novel, local common, and imported, which are classified by source (local or imported) and/or familiarity (novel or common). WillTry adjusted mean FV post-scores by highest exposure camp to lowest were 2.2, 2.3, and 2.2 for local novel and 2.6, 2.6, and 2.6 for local common. No differences among camps were significant; however, there was an increase in the willingness to try scores for all FV score types and camps. The Traditions pilot study demonstrated: (1) feasibility of a multi-arm parallel design using existing community programs in limited-resource environments and (2) further examination of nutrition education components and contexts are needed to understand diet behaviors of indigenous populations.

Chuukese Patients, Dual Role Interpreters, and Confidentiality: Exploring Clinic Interpretation Services for Reproductive Health Patients.

This exploratory study analyzes limited English proficient (LEP) Chuukese patients' perspectives on dual-role interpreters in Guam and Chuuk. Methods included ethnographic observations of encounters with health care workers (HCWs) and 225 female Chuukese patients seeking reproductive healthcare in community health clinics: 126 women in Guam and 99 women in Chuuk. Ethnographic observations were supplemented by semi-structured interviews with 26 HCWs, and life history interviews with 15 Chuukese transnational migrant women. Notes from interview transcripts and observations were analyzed using critical interpretive and grounded theory. Findings demonstrated that Chuukese LEP patients need and at times want interpreters in order to understand their healthcare visits. In the absence of professional interpreters, ad-hoc interpreters (family interpreters and employees of the clinic) are an important resource. However, social and cultural concerns with community confidentiality influenced patient trust of staff interpreters. This lack of trust can limit access to health care overall, as some patients may avoid seeking care to prevent their confidential health information being disclosed. These complexities in interpretation must be considered in order for clinics to provide optimal care for the communities they serve.

Migrant encounters in the clinic: Bureaucratic, biomedical, and community influences on patient interactions with front-line workers.

Ethnographic research on the clinical encounter has focused almost exclusively on what happens in exam rooms-particularly patient-provider interactions-leaving much to be understood about other actors within the clinic. As part of a larger ethnographic study examining the impact of colonialism, transnational migration, discrimination, and gender relations on Chuukese migrant women's reproductive and sexual health outcomes in Guam, I conducted eight months of participant observation in three publicly funded health clinics, 24 interviews with health care workers, and 15 life-history interviews with Chuukese women between September 2012 and February 2014. Findings demonstrated differential treatment of Chuukese patients by front-line workers (FLWs), who engaged in "boundary work" with these patients. Further, care varied by clinic space and the actors in that space. This differential treatment and variation in care impacted Chuukese women's access to and experiences with health care in Guam. Utilizing the concept of "deservingness," this analysis unpacks how FLWs, like Lipsky's "street-level bureaucrats," are influenced by bureaucratic, biomedical, and community hierarchies, all contributing to differential patient treatment. This study concludes by calling for more integrated analyses of clinical environments which utilize Lipsky's concept to include community narratives of "deservingness" and incorporate the influence of clinic and community stratification.

Sociocultural Factors that Affect Chewing Behaviors among Betel Nut Chewers and Ex-Chewers on Guam.

Areca nut (betel nut) is chewed by an estimated 10% of the world's population which is equivalent to about 600 million people. It is classified as a Group 1 carcinogen by the World Health Organization (WHO) and has been linked to various types of oral cancer. Chewing areca predominates in South and South East Asia, East Africa, and the Western Pacific and has important social and cultural implications. The purpose of the pilot study was twofold: (1) to examine sociocultural factors that affect why people on Guam chew betel nut, their chewing behaviors, perceptions of risks, probability of changing behaviors, and methods that could be used to reduce use or quit; and (2) to pilot two surveys (one for chewers and one for ex-chewers) to be used in a larger study in the future. A mixed methods design was employed that included surveys pertaining to their status (chewer or ex-chewer) and in-depth interviews. A total of 30 adults participated in this pilot study: adult betel nut chewers (n = 15) and ex-chewers (n = 15). Chewing betel nut is a learned behavior, embedded within the culture, and is viewed as an important cultural identifier. Socially, chewing is viewed as positive. Chewers stated that they were not as aware of health issues; however, ex-chewers stated health reasons for quitting.

Prevalence and incidence of dementia among indigenous populations: a systematic review.

BACKGROUND: Indigenous populations may be at increased risk, compared with majority populations, for the development of dementia due to lower education levels and socio-economic status, higher rates of diabetes, hypertension, cardiovascular disease and alcohol abuse, an aging population structure, and poorer overall health. This is the first systematic review investigating the prevalence and incidence of dementia in indigenous populations worldwide. METHODS: This systematic review was conducted in accordance with PRISMA guidelines. We searched MEDLINE, Embase, and PsycInfo for relevant papers published up to April 2015. Studies were included if they reported prevalence or incidence, the disease typically occurred after the age of 45, the study population included indigenous people, and the study was conducted in the general population. RESULTS: Fifteen studies representing five countries (Canada, Australia, the USA, Guam, Brazil) met the inclusion criteria. Dementia prevalence ranged from 0.5% to 20%. Retrospective studies relying on medical records for diagnoses had much lower prevalence rates and a higher risk of bias than population-based prospective studies performing their own diagnoses with culturally appropriate cognitive assessment methods. CONCLUSIONS: The prevalence of dementia among indigenous populations appears to be higher than it is for non-indigenous populations. Despite a building body of evidence supporting the need for dementia research among indigenous populations, there is a paucity of epidemiological research, none of which is of high quality.

The reasons for betel-quid chewing scale: assessment of factor structure, reliability, and validity.

BACKGROUND: Despite the fact that betel-quid is one of the most commonly used psychoactive substances worldwide and a major risk-factor for head-and-neck cancer incidence and mortality globally, currently no standardized instrument is available to assess the reasons why individuals chew betel-quid. A measure to assess reasons for chewing betel-quid could help researchers and clinicians develop prevention and treatment strategies. In the current study, we sought to develop and evaluate a self-report instrument for assessing the reasons for chewing betel quid which contributes toward the goal of developing effective interventions to reduce betel quid chewing in vulnerable populations. METHODS: The current study assessed the factor structure, reliability and convergent validity of the Reasons for Betel-quid Chewing Scale (RBCS), a newly developed 10 item measure adapted from several existing "reasons for smoking" scales. The measure was administered to 351 adult betel-quid chewers in Guam. RESULTS: Confirmatory factor analysis of this measure revealed a three factor structure: reinforcement, social/cultural, and stimulation. Further tests revealed strong support for the internal consistency and convergent validity of this three factor measure. CONCLUSION: The goal of designing an intervention to reduce betel-quid chewing necessitates an understanding of why chewers chew; the current study makes considerable contributions towards that objective.

Multiple neurotoxic items in the Chamorro diet link BMAA with ALS/PDC.

Beta-methyl-amino-L-alanine, (BMAA), is found in multiple components of the traditional Chamorro diet of Guam and this confounds epidemiological analysis based on a single dietary item. However, using hair as a non-invasive measure of BMAA exposure may help determine risks for developing motor neuron disease. BMAA found in brain tissues of patients with ALS/PDC and not generally in controls suggests that BMAA crosses the blood-brain barrier in patients with disease and is associated with neurodegenerative disease. An examination of frozen versus fixed autopsy tissue from ALS/PDC patients suggests that earlier studies of BMAA in ALS/PDC patients based on fixed tissues may have underestimated the concentration of BMAA in brain tissues. We suggest that the Chamorro people are exposed to chronically low levels of BMAA in the diet and that further research is needed to understand chronic BMAA toxicity.

Breast cancer screening among Chamorro women in California.

BACKGROUND: This study evaluated breast cancer-related knowledge, attitudes and behaviors among Chamorros in San Diego, California and compared mammogram use between those affiliated with the military and others. METHODS: A survey was administered to 110 self-reported Chamorro women. Inclusion criteria included being self-reported Chamorro woman >40 years with no history of breast cancer. Approximately equal proportions of participants with (52%) and without (48%) military affiliation were recruited to test the assumption that use of mammography differed between the two groups. Descriptive statistics and bivarate analyses were conducted. RESULTS: Of the 110 respondents, 42% had at least some college education, 41% had household incomes of at least $50,000, and 87% reported having health insurance. Approximately 93% reporting ever having a mammogram and 75% reported having it within the past 2 years. The difference between mammography use among women with and without military affiliation was not significant (85% versus 72%; p=0.11). However, women with military insurance (95%) were more likely than others (74%) to have had a mammogram within that time frame (p=.05). Other factors associated with higher mammography use included reporting better access to medical care (p=.03), receiving a recommendation for mammography from a health care provider (p=.002), and knowledge that cancer can be cured if detected early (p=.01) and that women should get a mammogram yearly (p=.01). CONCLUSION: Chamorro women in San Diego have relatively high rates of mammography use. This finding may be due, in part, to the relatively high rates of health insurance coverage (particularly military insurance) among these women.

Brain volumes in Guam dementia vs Parkinson dementia complex vs aging Chamorro adults.

We sought to determine if Chamorro individuals with a family history of Guam dementia (GD) or Parkinson dementia complex (PDC) exhibit presymptomatic brain MRI changes. Sixty-six Chamorro subjects had neurocognitive assessment and volumetric MRI. MRI brain volumes differed between diagnostic groups (GD, PDC, control) and according to family history. Chamorros with a family history of PDC or dementia may have increased brain atrophy, suggesting a hereditary susceptibility to neurodegenerative disorders.

Suicide and suicidal-related behaviors among indigenous Pacific Islanders in the United States.

The authors present a comprehensive review on U.S. Pacific Islander suicide and suicide-related behaviors to extend the knowledge and understanding of suicide and suicide-related behaviors among the indigenous peoples of the state of Hawai'i, the territories of American Samoa, Guam, Commonwealth of the Northern Mariana Islands, and the Pacific Island Nations of Micronesia (Federated States of Micronesia, the Republic of Belau [Palau], and the Republic of the Marshall Islands). Historical, geographic, epidemiological, social, and cultural information is presented on these Pacific Island populations. Suicide behavioral data are presented for Pacific Islanders living within the U.S. and affiliated Pacific territories and nations from the existing scientific literature along with archival data and 2 epidemiological studies that assess suicidal behaviors and related psychosocial factors and measures of psychopathology among large community samples of youth in Hawai'i. The authors describe common patterns and differences among these populations, along with social-cultural practices that may explain suicide phenomenology among these U.S. indigenous peoples who--while small in numbers when compared with the total U.S. population--possess striking health disparities when compared to other populations within the U.S. and in their island homelands.

Developing a community-based collaboration to reduce cancer health disparities among Pacific Islanders in California.

Cancer is a leading cause of death for Asians and Pacific Islanders in the United States, but education and research efforts addressing the needs ofPacific Islanders in the continental U.S. is sparse. The purpose of this paper is to describe the development of a community-based participatory research network dedicated to addressing cancer health disparities among Chamorros, Marshallese, Native Hawaiians, Samoans and Tongans in Southern California. Community-based organizations (CBO) comprise the focus of the network, and their efforts have included increasing cancer-related awareness in their communities, developing capacities regarding cancer control, and initiating collaborative research efforts with academic partners. First year processes and outcomes are described, and specific examples are given from two CBO partners.

Characterization of tau pathologies in gray and white matter of Guam parkinsonism-dementia complex.

Guam parkinsonism-dementia complex (PDC) is a neurodegenerative tauopathy in ethnic Chamorro residents of the Mariana Islands that manifests clinically with parkinsonism as well as dementia and is characterized neuropathologically by prominent cortical neuron loss in association with extensive telencephalic neurofibrillary tau pathology. To further characterize cortical gray and white matter tau, alpha-synuclein and lipid peroxidation pathologies in Guam PDC, we examined the brains of 17 Chamorro PDC and control subjects using biochemical and immunohistological techniques. We observed insoluble tau pathology in both gray and white matter of PDC and Guam control cases, with frontal and temporal lobes being most severely affected. Using phosphorylation dependent anti-tau antibodies, abundant tau inclusions were detected by immunohistochemistry in both neuronal and glial cells of the neocortex, while less alpha-synuclein pathology was observed in more limited brain regions. Further, in sharp contrast to Alzheimer's disease (AD), levels of the lipid peroxidation product 8, 12-iso-iPF(2alpha)-VI isoprostane were not elevated in Guam PDC brains relative to controls. Thus, although the tau pathologies of Guam PDC share similarities with AD, the composite Guam PDC neuropathology profile of tau, alpha-synuclein and 8, 12-iso-iPF(2alpha)-VI isoprostane reported here more closely resembles that seen in other tauopathies including frontotemporal dementias (FTDs), which may imply that Guam PDC and FTD tauopathies share underlying mechanisms of neurodegeneration.

Amyotrophic lateral sclerosis/parkinsonism dementia complex: transgenic mice provide insights into mechanisms underlying a common tauopathy in an ethnic minority on Guam.

Intracytoplasmic filamentous tau inclusions are neuropathological hallmarks of amyotrophic lateral sclerosis/parkinsonism-dementia complex (ALS/PDC) of Guam and the defining lesions of other neurodegenerative disorders known as tauopathies. Here we review current insights into the cell and molecular neuropathology of ALS/PDC, a common tauopathy in the Chamorro population on Guam. We also summarize recent advances in understanding this disorder through studies of transgenic (Tg) mouse models of this tauopathy. Briefly, overexpression of human tau isoforms in the central nervous system of Tg mice resulted in a neurodegenerative tauopathy with a phenotype similar to ALS/PDC. Specifically, argyrophilic, congophilic, and tau immunoreactive inclusions accumulated with age in cortical and brainstem neurons of these mice, but they were most abundant in spinal cord neurons, and the inclusions contained 10- to 20-nm tau-positive straight filaments. There also was extensive gliosis in spinal cord associated with axonal degeneration in the ventral roots, while remaining axons in spinal nerves showed a loss of microtubules and reduced fast axonal transport. With advancing age, these Tg mice showed increasing motor weakness, and this was accompanied by a progressive increase in the phosphorylation and insolubility of brain and spinal cord tau proteins. Thus, tau Tg mice recapitulate key phenotypic features of ALS/PDC neuropathology in an ethnic minority on Guam, and these animal models provide new opportunities to discover novel therapies for this and related tauopathies.

Neurofibrillary tangles in the primary motor cortex in Guamanian amyotrophic lateral sclerosis/parkinsonism-dementia complex.

The amyotrophic lateral sclerosis/parkinsonism-dementia complex is a chronic neurodegenerative disorder with high prevalence among the native Chamorro population of Guam. The cortical pathology of the disease is characterized by the widespread occurrence of cortical neurofibrillary tangles that exhibit a specific laminar and regional distribution different from that seen in Alzheimer's disease (AD). In spite of the major motor symptomatology, the degree to which the primary motor cortex is affected in this disease has not been investigated in detail. We report here that the primary motor cortex in Guamanian cases contains high numbers of neurofibrillary tangles, contrasting sharply with the situation in AD and in non-Chamorro cases of amyotrophic lateral sclerosis. Furthermore, the cases with predominant parkinsonism-dementia are more severely affected than amyotrophic lateral sclerosis cases. These data suggest that the regional and cellular pathology of Guamanian cases differs radically from that commonly observed in neurodegenerative diseases outside Guam and point to the existence of subgroups in the spectrum of clinical manifestations seen in Guamanian patients.

Breast cancer screening among Chamorro women in southern California.

Breast cancer is the most common cancer in Pacific Islander women, yet relatively little is known about their cancer risks and screening behaviors. Chamorros are indigenous people from Guam, and California is home to the largest numbers of Chamorros on the mainland United States. This study examined the breast cancer risk, knowledge, and screening behaviors in a nonprobability sample of Chamorro women age 40 years and older in Los Angeles and Orange Counties (n = 227). The proportional incidence ratio for breast cancer among Chamorro women was found to be 0.7 compared with white women in California, indicating a lower current breast cancer risk for Chamorro women compared with white women. Thirty-seven percent of respondents ever performed a breast self-examination (BSE), 93% ever had a clinical breast examination (CBE), and 77% ever had a mammogram. In terms of screening maintenance, only 27% did BSE monthly, 66% received a CBE in the past year, and 25% received yearly mammograms. Significant correlates of CBE were higher educational attainment, married status, higher income, and health insurance coverage. Women who knew of breast cancer symptoms, would undergo treatment, and would like to know if they had breast cancer were also more likely to have ever had a CBE. With regard to mammography, older age, moderate income, married status, and use of traditional healers and healing practices were associated with higher screening incidence. Implications of these findings for developing culturally tailored and appropriate cancer screening programs are discussed.

Substantia nigra in progressive supranuclear palsy, corticobasal degeneration, and parkinsonism-dementia complex of Guam: specific pathological features.

Disease-specific findings in the substantia nigra were examined in cases of progressive supranuclear palsy (PSP), corticobasal degeneration (CBD), and parkinsonism-dementia complex of Guam (PDC); diseases in which the patients exhibit dementia and parkinsonism, with neurofibrillary tangles (NFTs) and glial tangles composed of hyperphosphorylated tau. Loss of pigmented neurons was extremely severe in these 3 diseases, and decrease of the nonpigmented neurons was severe in PSP and CBD. On the other hand, in PDC the decrease of the nonpigmented neurons was different in each patient. Topographically, in PSP the nonpigmented neurons were particularly depleted in the ventral part and relative preservation of the pigmented neurons was observed in the medial part at the level examined. Many NFTs were observed in PDC. Although the number of NFTs was small, many pretangles were seen in the neurons in CBD. Granular and hazy astrocytic inclusions were identified exclusively in PDC. Numerous argyrophilic neuropile threads were identified in CBD and PSP, but these were few in PDC. Many foamy spheroid bodies as well as coiled bodies were observed in PSP and CBD, but only a few were observed in PDC. In conclusion, PDC is a disease that is distinctly different from PSP and CBD. It is possible to differentiate between PSP and CBD by the occurrence of many pretangles in CBD, but some similarities between these 2 diseases indicate the existence of common pathological mechanisms.

Cross-cultural comparison of health perceptions, concerns, and coping strategies among Asian and Pacific Islander American elders.

This article compares the health perceptions, concerns, and coping strategies among elders in two Asian and Pacific Islander American communities. The qualitative comparison is conducted between elder Chamorros of Guam and elder Chinese of the United States, using a focused ethnography for data collection and the grounded theory method for cross-cultural analysis. The health perceptions of these two communities are manifest in two themes: (a) a sense of holism among body, mind, and spirit and (b) an orientation toward others. The health concerns of these two communities include universal experiences of aging, structural elements within the American health care system, and cultural changes impacting health. A significant coping strategy is adaptation to changes while maintaining continuity. Finally, implications for the delivery of culturally appropriate health care services to Asian and Pacific Islander American elders are discussed.