Native Hawaiian Women Research Articles

The story of Wānanalua: Stranded whales and contested marine sovereignties in Hawai‘i

This paper considers how systems of interspecies knowing and care in Hawai'i push against state-supported frameworks of liberal biopolitical governance. In 2015, the National Oceanic and Atmospheric Administration (NOAA) issued a citation two Kanaka Maoli (Native Hawaiian) women under the Marine Mammal Protection Act, for unlawfully “tak[ing] and/or or transporting” a stranded melon-headed whale (“Wānanalua”). In the lawsuit, prosecutors deliberated on the legality of the traditional sea burial situating it within a broader context of cultural accommodations granted by National Oceanic and Atmospheric Administration. From our examination of the lawsuit, we develop the argument that marine mammal care operates in Hawaiʻi as a regulatory device for ordering interspecies relations and for pacifying Indigenous demands for greater marine political authority. To combine these claims, we consider the relation between two governance logics: liberal “recognition,” wherein accommodations regarding culture are extended to previously disenfranchised social groups, and biopolitics, pertaining in the present case to care practices governing more-than-human actors and environments. Our arguments are supported by detailed case files and interviews with local informants, including the Kanaka women accused of mishandling Wānanalua. The “ruptures” marking the Wānanalua case suggest a liberal recognition framework whose failures are connected to the biopolitics it embraces, but with an added detail: The present story reflects on how an interspecies biopolitics—an attempted management of Kānaka-whale care practices—structures strategies of liberal recognition.

Editorial Note: Suffrage and Beyond: Celebrating Women's History

Editorial NoteSuffrage and Beyond: Celebrating Women's History Elisa Camiscioli and Jean H. Quataert 2020 is the centennial year of the granting of women's suffrage in the United States through state ratification of the Nineteenth Amendment. Many diverse celebrations are planned to commemorate the anniversary, from museum exhibits and symposia to workshops and concerts. Indeed, as we write, local singers in Binghamton, New York already performed a concert called "Women of Note," featuring music composed by women and highlighting suffragist songs. The anniversary is a milestone of sorts. Suffrage was a cardinal aim of feminist mobilizations across the globe over the past two centuries, and the topic has spurred a vibrant yet increasingly critical historiography. With this issue, the JWH brings the insights of women's historians to the celebration. We open with a Special Forum that asks, provocatively, "What Difference Did the Nineteenth Amendment Make?" The Forum is guest edited by Liette Gidlow who proposed, organized, and edited it. She brings together six leading women's historians who write about the topic from different regional, class, and race perspectives. As Gidlow writes in her introduction, the authors extend the moment of 1920 "both backward and forward in time," inserting the suffrage question into the history of US imperial expansion and exploring the meanings of inclusion in—and exclusion from—the nation as the ranks of the voting public expanded. Each contribution to the Forum offers valuable documentary and historiographical details in a length easily adaptable for teaching purposes. Lori D. Ginzberg writes from the perspective of the women advocates themselves. She shows that over the decades, the consistent call for the women's vote reflected different rationales. She explores a "radical reimagining of political, religious, and marital hierarchies" inherent in suffrage claims in the antebellum era. She then examines the compromises suffrage advocates accepted around the turn of the century, a "tactical shift" that required concessions to white supremacy and to notions of women's purity. These political accommodations, Ginzberg writes, made suffrage "mainstream, respectable, and safe," setting the stage for 1920 itself—although the vote "left many things unsorted." Rosalyn Terborg-Penn looks at the outcome for African American women. Terborg-Penn, recently deceased, was a pioneer in the field of African American women's suffrage history, and Gidlow's introduction includes a fitting tribute to her pathfinding scholarship and their collaboration in this Special Forum. In her essay, Terborg-Penn examines the fraught history of suffrage for Black women and men who, soon after [End Page 7] ratification, lost the right to vote in the South. Her main story deals with Black women's formative role in the women's suffrage movement prior to 1920 and their subsequent mobilization strategies for the ballot through the Civil Rights era of the 1960s. Looking outside the formal borders of the United States, Rumi Yasutake takes us to Hawai'i, at the time a US territory. She focuses on Native Hawaiian women suffragists who seized the vote as a "means to recover their political and economic rights lost in the modern American system," including the right to hold office. In the next contribution by Cathleen D. Cahill, the vote is examined in the longer context of Native American history. Cahill explores the topic through the writings of two Native feminist intellectuals who creatively intertwined citizenship with sovereignty for Native Nations. Gidlow's own essay rounds out the Special Forum. She provides trenchant historical reassessment of the many sides to the "rise of the 'Women's Vote.'" In her telling, suffrage helped revive the Ku Klux Klan in the 1920s; it transformed a piecemeal strategy known as the "white primary" into a uniform policy that effectively barred "Black voters from local Democratic Party organizations"; turned the Republican Party after 1965 into a white party when southern white conservative Democrats defected to it; and shaped the "racial politics of the feminist movements." Since 1976, the women's vote, Gidlow observes, elevated Black women into a key constituency of the Democratic Party—on full display in the 2018 midterm elections in the Trump era. This issue also includes three article-length pieces. As in the Special Forum on women's suffrage...

Embodying Haumea: wāhine scholars cultivating Kanaka independence/ts in the academy

In this paper, we, a collective of wāhine ʻŌiwi (Native Hawaiian women), reflect on how we may hoʻokō (fulfill) our kuleana lāhui (nation-building responsibilities) through our positions in the academy. While doing this work has always already been tenuous given the occupied state of ka Lāhui Hawaiʻi (the Hawaiian nation), this tenuousness and the stakes of this work are perhaps even higher within the current political climate of the United States. Through dialogue, we consider the ways that we have striven to kūʻē (resist, stand up) through our research, teaching, and service and express our hopes for the students and broader community we hope to serve.

Propensity for Intra-abdominal and Hepatic Adiposity Varies Among Ethnic Groups

We compared fat storage in the abdominal region among individuals from 5 different ethnic-racial groups to determine whether fat storage is associated with disparities observed in metabolic syndrome and other obesity-associated diseases. We collected data from 1794 participants in the Multiethnic Cohort Study (60-77 years old; of African, European [white], Japanese, Latino, or Native Hawaiian ancestry) with body mass index values of 17.1-46.2 kg/m2. From May 2013 through April 2016, participants visited the study clinic to undergo body measurements, an interview, and a blood collection. Participants were evaluated by dual-energy x-ray absorptiometry and abdominal magnetic resonance imaging. Among ethnic groups, we compared adiposity of the trunk, intra-abdominal visceral cavity, and liver, adjusting for total fat mass; we evaluated the association of adult weight change with abdominal adiposity; and we examined the prevalence of metabolic syndrome mediated by abdominal adiposity. Relative amounts of trunk, visceral, and liver fat varied significantly with ethnicity-they were highest in Japanese Americans, lowest in African Americans, and intermediate in the other groups. Compared with African Americans, the mean visceral fat area was 45% and 73% greater in Japanese American men and women, respectively, and the mean measurements of liver fat were 61% and 122% greater in Japanese American men and women. The visceral and hepatic adiposity associated with weight gain since participants were 21 years old varied in a similar pattern among ethnic-racial groups. In the mediation analysis, visceral and liver fat jointly accounted for a statistically significant fraction of the difference in metabolic syndrome prevalence, compared with white persons, for African Americans, Japanese Americans, and Native Hawaiian women, independently of total fat mass. In an analysis of data from the participants in the Multiethnic Cohort Study, we found extensive differences among ethnic-racial groups in the propensity to store fat intra-abdominally. This observation should be considered by clinicians in the prevention and early detection of metabolic disorders.

Depression and Help-Seeking Among Native Hawaiian Women.

The purpose of this mixed-methods study was to gain insight about Native Hawaiian (NH) women's experiences with, and viewpoints of, depression and help-seeking behaviors (N= 30: 10 from the university and 20 from the community). More women reported depression in the interviews than through their Center for Epidemiologic Studies Depression Scale (CES-D) responses. Quantitative data revealed 57% of the women had ever received mental health help (80% of university vs. 45% of community sample). There was a range of satisfaction reported for various types of mental health care, with satisfaction being the highest for spiritual/religious advisor/folk healer. During the interviews, one woman reported that she is currently receiving professional care and five women are seeking help from their family/social network. Future research should explore reasons for the differences in the quantitative and qualitative findings regarding depression and associated help-seeking as well as in the satisfaction levels by type of help-seeking.

Abstract 2286: Atopic allergic conditions and risk of pancreatic cancer: the Multiethnic Cohort

Abstract Background: Previous studies, mostly case-control studies, have suggested that atopic allergic conditions (AACs) are associated with a decreased risk of pancreatic cancer. Scarce data, however, are available from prospective, US multiethnic populations. In this largest prospective study to date, we investigated the association between AACs (asthma, hay fever, or allergy) and risk of developing pancreatic cancer in the US Multiethnic Cohort Study (MEC). Methods: AACs were assessed via a baseline questionnaire when participants joined the MEC in 1993-1996. Hazard ratios (HRs) and 95% confidence intervals (CIs) for pancreatic cancer incidence by AACs status were calculated using Cox regression, adjusting for age, sex, race/ethnicity, education, smoking status, family history of pancreatic cancer, body mass index, diabetes, and alcohol intake. Results: During an average of 16.2-year follow-up, 1,455 incident cases of pancreatic cancer were identified among 187,226 white, African-American, Native Hawaiian, Japanese-American, and Latino men and women. AACs were not associated with pancreatic cancer incidence (HR=1.00; 95% CI: 0.88, 1.12). The null association was observed in men and women and across racial/ethnic groups, smoking status, BMI groups, diabetes status, and family history of pancreatic cancer. Conclusions: Based on these results, AACs is unlikely to be associated with risk of pancreatic cancer. Citation Format: Brian Z. Huang, Loic Le Marchand, Christopher A. Haiman, Kristine Monroe, Lynne Wilkens, Zuo-Feng Zhang, Veronica Wendy Setiawan. Atopic allergic conditions and risk of pancreatic cancer: the Multiethnic Cohort [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2286. doi:10.1158/1538-7445.AM2017-2286

Abstract LB-164: The association between p53, MDM2, and MDM2 isoform C protein expression and survival in a multiethnic population of breast cancer patients

Abstract Breast cancer is the most common cancer among women in the United States. Despite improvements in survival rates, the disease remains the second leading cause of cancer death for women in the U.S. Breast cancer incidence and survival dramatically vary by race and ethnicity. These disparities may be attributed to racial/ethnic differences in the factors influencing breast cancer development and progression. These include factors such as personal (eg. body size and reproductive history), clinical (eg. stage, grade, histology), treatment course, and genetic susceptibility. Inactivation of the tumor suppressing, p53 pathway is a common event in breast cancer. Depending on the molecular subtype, p53 mutation is observed in 12-84% of breast cancers and is correlated with poor clinical outcome. In addition to p53 mutation events, p53 pathway inactivation in tumors can also result from an increase in the levels of MDM2, an ubiquitin ligase that functions as a negative regulator of p53. The mdm2 gene produces at least 40 differentially spliced transcripts. The MDM2 isoforms A, B, and C have been observed to be frequently overexpressed in many tumor types and correlated with poor prognosis, however, the underlying mechanism is poorly understood. To examine the protein expression profiles for p53, MDM2, and MDM2 isoform C (MDM2-C) in breast cancer from a multiethnic population, we conducted immunohistochemical (IHC) analyses utilizing commercially available antibodies to p53 and MDM2, and a newly developed monoclonal antibody specific for MDM2-C (Okoro DR et al. 2013. PLoS ONE) on a total of 791 invasive breast tumors included in a clinically-annotated population-based tissue microarray (TMA). Based on Cox proportional hazards regression analysis and adjusting for age, stage, and estrogen and progesterone receptor status, we did not observe significant associations between expression of p53, MDM2, or MDM2-C and mortality across all cases. However when we examined associations within major racial/ethnic groups included in our TMA (Caucasian, Japanese, and Native Hawaiian), we observed a significant positive association of p53 expression (HR=1.63, 95% CI: 1.02-2.59) and a marginally significant association of MDM2-C (HR=1.69, 95% CI: 0.94-3.01) with all-cause mortality for Japanese women. We also observed associations between MDM2-C expression and all-cause and breast cancer-specific mortality for Caucasian women (HR=0.60, 95% CI: 0.33-1.08 and HR=0.28, 95% CI: 0.12-0.67, respectively). However, in contrast to Japanese women, expression of MDM2-C was associated with lower risk of mortality for Caucasian women. No significant associations for Native Hawaiian women were observed. Recent reports indicate that the functional effects of MDM2 isoforms (A, B, and C) are dependent on the presence of wild-type or mutant p53, and our preliminary results suggest that the association between breast cancer outcome and MDM2-C expression is context dependent on p53 status. Citation Format: Lenora W. Loo, Brenda Y. Hernandez, Yurii Shvetsov, Danielle Okoro, Chong Gao, Jill Bargonetti. The association between p53, MDM2, and MDM2 isoform C protein expression and survival in a multiethnic population of breast cancer patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr LB-164. doi:10.1158/1538-7445.AM2017-LB-164

Contraceptive decision making among native Hawaiian women

Contraceptive decision making among native Hawaiian women

Abstract SY02-04: Risk factors associated with cancer, type 2 diabetes, and cardiovascular disease in the multiethnic cohort: Comparisons across ethnic groups

Abstract Many chronic diseases common in the United States, such as cancer, type II diabetes and cardiovascular disease, share many lifestyle risk factors, such as tobacco use, obesity, diet, and lack of physical activity. These factors likely act upon disease through common pathways, such as inflammation and immune suppression. Examining the association of these risk factors with chronic conditions within a cohort could provide insights into their roles in the etiology of cancer and disease in general. The Multiethnic Cohort (MEC) is a prospective study that enrolled over 215,000 individuals in Hawaii and California from 1993 to 1996. The cohort is largely comprised of five major ethnic groups: African American, Native Hawaiian, Japanese American, Latino and white. The cohort is followed for disease endpoints via passive and active means. Cancer cases are identified through linkage to SEER registries in the two states, and deaths are identified through linkage to state and national death registries. Other conditions, such as type II diabetes and cardiac events are identified through self-reported and linkage to health care systems, such as Medicare and hospital discharge data. Within the MEC, the risk of cancer varies by ethnic group and a focus has been on finding genetic and lifestyle risk factors that explain these differences. The influence of pre-existing chronic conditions is examined in terms of whether they explain some of the ethnic differences in cancer risk and whether they modify the associations for lifestyle factors. The chronic conditions considered was prior cancer, diabetes, hypertension, coronary heart disease and stroke. As tobacco use is such a strong predictor of smoking related cancers, such as oral and lung cancer, they will not be included. The focus is on cancer more related to hormonal and metabolic factors, such as cancers of the breast, colon, prostate, and endometrium. For breast cancer, the Native Hawaiian women are at 50% higher risk and Latinas are at 27% lower risk, compared to white women, after adjustment for known risk factors. The presence of condition conditions at baseline was associated with a 14% higher risk of breast cancer, which was consistent across racial/ethnic groups. This did not differ by type of chronic condition. Adjustment for chronic condition did attenuate the associations for lifestyle factors, such as obesity, and there were modest differences in this attenuation by ethnic group. The presentation will be expanded to additional cancer sites and risk factors. In addition, also explored will be whether risk factors are similar in individuals with only a cancer diagnosis compared to those with the diagnosis of multiple chronic conditions within a short time window. Any differential findings will be interpreted in light of possible pathways affected. Citation Format: Lynne Wilkens. Risk factors associated with cancer, type 2 diabetes, and cardiovascular disease in the multiethnic cohort: Comparisons across ethnic groups. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr SY02-04. doi:10.1158/1538-7445.AM2015-SY02-04

Abstract 882: Obesity, comorbidity and endometrial cancer survival: the multiethnic cohort

Abstract Background: Endometrial cancer (EC) is the most common gynecologic cancer diagnosed in the United States. With >750,000 survivors in 2014, EC comprises the second largest group of female cancer survivors. Higher body mass index (BMI) and other medical comorbidities have been suggested to negatively impact EC survival; however, data in minority populations with rising EC incidence and mortality (i.e. Asian Americans, African Americans, Latinas, etc.) are scarce. We examined the association of pre-diagnostic BMI and obesity-related comorbidities with overall survival in African-American, Japanese, Native Hawaiian, Latino and white women in the Multiethnic Cohort. Methods: Women with complete risk factor data who developed endometrial cancer during follow up were included in the analysis (N = 998). BMI and obesity-related comorbidities (diabetes, hypertension, heart attack and stroke) were self-reported at cohort entry and at subsequent follow-ups. Cox's models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) with time-varying exposures in relation to all-cause mortality while adjusting for age at diagnosis, tumor characteristics, treatment, and education. Results: The mean age at EC diagnosis was 67.7 ± 8.5 years. The mean follow-up period was 7.3 ± 5.3 years from diagnosis to death or end of follow up during which time a total of 323 deaths were observed, 84 (26%) of which were due to EC. The mean BMI was 29.9 kg/m2 and 53% of women had at least one comorbid condition. The prevalence of obesity and comorbid conditions varied across ethnic groups (P<0.0001). The prevalence of obesity (BMI ≥30 kg/m2) ranged from 18% in Japanese Americans to 69% in Hawaiians. The prevalence of women with at least one comorbid condition ranged from 38% in whites to 76% in African Americans. Women with a BMI ≥35 kg/m2 had an increased risk of all-cause mortality [HR = 1.55 (95% CI: 1.06, 2.28)] compared with women with BMI <25 kg/m2. Women with two or more comorbid conditions also had a higher risk of all-cause mortality (HR = 1.61; 95% CI: 1.12, 2.31) compared to those with no medical comorbidities. There was evidence of ethnic differences in the comorbidity and all-cause mortality association (P interaction = 0.02); the presence of two or more comorbidities was significantly associated with all-cause mortality in whites (HR = 2.98; 95% CI: 1.34, 6.63) and Japanese Americans (HR = 3.47; 95% CI: 1.19, 10.14), but not in African Americans (HR = 0.88; 95% CI: 0.42, 1.82), Latinas (HR = 1.16; 95% CI: 0.45, 2.96), and Native Hawaiians (HR = 0.95; 95% CI: 0.22, 4.02). Conclusions: Our results show that higher pre-diagnosis BMI and the presence of two or more comorbidities increase the risk of overall death among multiethnic women diagnosed with EC. Clear identification and targeted managements of these conditions may improve overall survival after EC diagnosis. Citation Format: Veronica Wendy Setiawan, Gertraud Maskarinec, Yvonne G. Lin, Dongyun Yang, Lynne R. Wilkens, Brian E. Henderson, Loic Le Marchand. Obesity, comorbidity and endometrial cancer survival: the multiethnic cohort. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 882. doi:10.1158/1538-7445.AM2015-882

Pa'u Riding in Hawai'i: Memory, Race, and Community on Parade

In parades across Hawai‘i, women participate in an event called pa‘u riding. Eight princesses, a queen, and numerous attendants ride horseback, wearing flowing pa‘u skirts and looking like beauty queens. These women view themselves as representatives of Hawaiian history, but this display of historical memory is anything but straightforward. The event fosters a sense of local community and history, yet it paradoxically also showcases fractious divisions in Hawaiian society. Controversy exists as to which women legitimately can be pa‘u princesses. Although pa‘u riding was originally founded by upper-class white women, the pa‘u skirt has connections to the native Hawaiian hula, and the riding form has been used as a symbol of indigenous protest by native Hawaiian women. Today, Hawaiian women of a variety of ethnic identities use pa‘u riding to engage in a postcolonial debate about memory, race, and belonging.

Abstract A39: Informing community-based participatory research in the Pacific Islander community: The PIC Health (Pacific Islander Community Health) Study

Abstract Background: Native Hawaiians and Pacific Islanders (NHPI) are 30 percent more likely to be diagnosed with cancer compared to Whites. Even compared to other minority groups, NHPI disproportionately experience late stage diagnosis and death due to cancer. Cervical and breast cancer is seen almost twice as much for Native Hawaiian and Samoan women. Samoan men are eight times more likely to have liver cancer and five times more likely have stomach cancer. Lung and stomach cancer are also high among Native Hawaiian men and women. While these statistics are alarming for NHPI, we are just beginning to understand how to intervene to address cancer health disparities, especially in ways that are culturally sensitive. Methods: Our first objective was to form a NHPI Research Advisory Board in San Diego, which includes Pacific Islander community leaders, members, and health professionals. The advisory board is central in building academic-community partnerships and in helping to guide and monitor research efforts in this study. The objective of this project is to, first, work with the NHPI community in San Diego to gather information from key informant interviews and focus groups. This type of qualitative data will help us understand best practices for recruitment, culturally sensitive strategies for engaging the community, and to assess risk behavior and knowledge around cancer screening, including the identification of barriers. Second, with this information, we will develop and administer a survey and collect height, weight, and physical activity data from NHPIs. This abstract presents the qualitative findings, to date. Interviews from key informants and focus groups were audio-taped, transcribed, and uploaded into ATLAS.ti, a software used for qualitative coding and analysis. Dr. Holub and one trained research assistant coded and extracted themes from the interview/focus group transcripts. A deductive coding start list was pre-determined based on literature. Additionally, emerging codes (inductive) were allowed based on the transcripts. Since “talk story” formats are important in the NHPI culture, we emphasized coding “in vivo”, by using direct quotes or culturally meaningful words. This will allow codes to emerge from the participants' own language. Results: From January to July 2013, we conducted 10 key informant interviews and 3 focus groups. All together, participants included: 14 Native Hawaiians (39%), 7 Samoans (19%), 2 Tongans (6%), 10 Chamorros (28%), 1 Filipino (3%), and 2 Marshallese (6%). Four major themes addressed reach, barriers, and potential health topics for a community-based health intervention in the Pacific Islander community: (1) Ways to reach Pacific Islanders: social clubs (e.g., Hawaiian Civic Club), churches (Samoan and Tongan), radio and TV, and festivals (e.g., the Pacific Islander Festival Association of San Diego); (2) Potential barriers to participating in a health program: transportation, family care, and not knowing you personally (lack of trust); (3) Ways to overcome barriers: personal invitations, build trust, work with community leaders, express why it is important to participate in a health study, and highlight benefits to the community; (4) Health topic interests of the community: diabetes, obesity, nutrition (especially portion control), access to healthcare, heart disease, smoking, alcohol use, and cancer. Future Implications: The outcomes of this study will advance the field by providing essential, culturally-relevant information for addressing cancer health disparities in the NHPI community. Citation Format: Christina K. Holub. Informing community-based participatory research in the Pacific Islander community: The PIC Health (Pacific Islander Community Health) Study. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A39. doi:10.1158/1538-7755.DISP13-A39

Abstract PL02-03: Overcoming cultural and geographic barriers to participation in clinical trials among Native Hawaiians

Abstract The Native Hawaiian population of Hawaii has disproportionately high cancer incidence and mortality rates. Native Hawaiian women with breast cancer present at an advanced stage and have death rates that are 52 % above the state average. Prostate cancer among Native Hawaiian men is diagnosed at more advanced stage. Native Hawaiian participation in cancer clinical trials was historically low. Reasons for this were varied including access, health literacy, lack of primary and referring physician awareness/time constraints and cultural barriers. Since the establishment of the University of Hawaii Minority Based Clinical Oncology Program (UHMBCCOP) participation in cancer clinical trials has definitely increased. MBCCOP provided clinical trial promotion, increased access and clinical trial support for a group of hospital and office based oncologists across the islands of Oahu and Kauai have all contributed to the increase. Education programs in Hawaii by multiple organizations, in particular, Imi Hale, the Native Hawaiian Cancer Network Program have enhanced knowledge of cancer and clinical trials in the Native Hawaiian community. Imi Hale's emphasis has focused on community based patient training, patient navigation and referring physician cancer clinical trial training. In fact, a recent program was recently initiated in conjunction with Education Network to Advance Clinical Trials (ENNACT) and Queens Medical Center. Review of Native Hawaiian participation in both cancer prevention and treatment trials through the UHMBCCOP over the last 20 years shows a significant gender difference with more women participating in both prevention and treatment trials. The reasons for this are not well understood but are under investigation. In summary, increased focused access and community based education have improved Native Hawaiian participation in cancer clinical trials but challenges persist including gender disparities in enrollment onto clinical trials and lack of access outside of Oahu and Kauai islands. Citation Format: Jeffrey L. Berenberg. Overcoming cultural and geographic barriers to participation in clinical trials among Native Hawaiians. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr PL02-03. doi:10.1158/1538-7755.DISP13-PL02-03

Abstract PR9: Diabetes and racial/ethnic differences in hepatocellular carcinoma risk: The Multiethnic Cohort

Abstract Background: Hepatocellular carcinoma (HCC) incidence has tripled in the US over the past three decades. Diabetes has been suggested as an emerging risk factor for HCC and its increasing prevalence may contribute to the rising incidence of HCC. Data from prospective studies on the relationship between diabetes and HCC in multiethnic populations are scarce. Here we examined whether the association between diabetes and HCC risk differs across racial/ethnic groups, and whether the association is modified by known HCC risk factors. Methods: We conducted a prospective analysis of 169,479 African-American, Native Hawaiian, Japanese-American, Latino and white men and women who were recruited into the Multiethnic Cohort (MEC) Study between 1993 and 1996. During a median follow-up period of 15.7 years, a total of 506 incident HCC cases (59 whites, 81 African Americans, 33 Hawaiians, 158 Japanese, and 175 Latinos) were identified among the cohort participants. Data on known and suspected risk factors were obtained from baseline questionnaire. Serologic testing for hepatitis B (HBV) and C (HCV) infection was performed on a subset of cohort subjects (233 cases and 460 non cases). Cox proportional hazards models stratified by sex and adjusted for age, alcohol drinking, body mass index (BMI in kg/m2) and cigarette smoking were used to calculate relative risks (RRs) and 95% confidence intervals (CIs) for HCC associated with diabetes for each ethnic group. The population attributable risk percent associated with diabetes was also calculated for each ethnic group. Results: Incidence rates of HCC markedly differed across race/ethnic groups; the age-adjusted RRs for HCC (vs. whites) were 2.77 (95% CI: 2.03, 3.78) for Latinos, 2.48 (95% CI: 1.59, 3.86) for Native Hawaiians, 2.16 (95% CI: 1.52, 3.07) for African Americans, and 2.07 (95% CI: 1.51, 2.38) for Japanese. The age- and sex-adjusted prevalence of diabetes at baseline also varied across ethnic groups: 16% in Hawaiians, 15% in Latinos, 15% in African Americans, 10% in Japanese, and 6% whites (P<0.0001). Diabetes was strongly associated with HCC risk in all ethnic groups (P-heterogeneity=0.40); the RR was 3.33 (95% CI: 2.39, 4.63) in Latinos, 2.54 (95% CI: 1.13, 5.70) in Hawaiians, 2.33 (95% CI: 1.60, 3.40) in Japanese, 2.02 (95% CI: 1.17, 3.49) in African Americans, and 2.17 (95% CI: 0.95, 4.93) in whites. BMI, smoking status, and alcohol intake did not modify the diabetes-HCC association (P interaction ≥ 0.19). Within a subset of cohort participants with available HBV and HCV serologic data, diabetes was not associated with infection status (P ≥ 0.07). We estimated that 26% of HCC cases in Latinos, 20% in Hawaiians, 13% in African Americans, 12% in Japanese, and 6% in whites were attributed to diabetes. Conclusions: In the MEC, Latinos were at the highest risk of developing HCC, followed by Native Hawaiians, African Americans, Japanese and whites. We showed that diabetes is a strong risk factor for HCC in all ethnic groups and that the inter-ethnic differences in the prevalence of diabetes was consistent with the pattern of HCC incidence observed across ethnicities. Finally, we showed that eliminating diabetes could potentially reduce HCC incidence in all racial/ethnic groups, with the largest potential for reduction in Latinos. This abstract is also presented as Poster C91. Citation Format: Veronica Wendy Setiawan, Brenda Hernandez, Daniel Stram, Lynne Wilkens, Loic Le Marchand, Brian E. Henderson. Diabetes and racial/ethnic differences in hepatocellular carcinoma risk: The Multiethnic Cohort. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr PR9. doi:10.1158/1538-7755.DISP13-PR9

Abstract 3264: IGF-axis protein expression and survival in Native Hawaiian breast cancer patients

Abstract Obesity-induced and related aberrations in insulin signaling may contribute to differences in breast cancer risk and outcome across racial/ethnic populations. The mechanisms underlying breast cancer disparities among Asian and Pacific Islander populations in the U.S. (specifically the high risk and poor survival of Native Hawaiians) are unknown. We examined the expression of IGF-axis proteins (IGF1, IGF1R, IGFBP2, and IGFBP3) in archived tumor tissue from 358 invasive breast cancer patients diagnosed in Hawaii. Overall and breast cancer-specific survival were evaluated via Kaplan-Meier curves and Cox's proportional hazards regression. Covariates included demographic and clinical factors, ER/PR/HER2 status, and for a subset of patients participating in the Multiethnic Cohort (MEC) (n=104), history of obesity, diabetes, and estrogen use at baseline. Across all cases, expression of the IGF-axis proteins in tumors did not differ by race/ethnicity. In the MEC subset, IGF1 expression was observed in 22% of estrogen users compared to 46% of non-users (p=0.04) and expression of IGFBP2 was observed in 71% of estrogen users compared to 93% of non-users (p=0.02). Protein expression did not vary by body mass index (BMI) or diabetes history. Obesity was most prevalent in Native Hawaiians (72%) and lowest in Japanese Americans (2%) (p<0.0001). History of estrogen use was highest in whites (73%) and lowest in Native Hawaiians (28%) (p=0.008). Across all MEC patients, IGFBP2 expression was associated with shorter breast cancer-specific survival after adjustment for age, stage, first-course of treatment, ER, PR, HER2, and estrogen use (HR=2.23, 95% CI 1.03-4.85). When examined by individual race/ethnic groups across all patients, overall and breast cancer-specific survival did not vary by IGF-axis protein expression for whites, Japanese, Filipinos, or Chinese. Among Native Hawaiians, IGFBP2 and IGFBP3 expression was associated with shorter overall survival when adjusted for age, stage, first-course of treatment, ER, PR, and HER2 (HR=10.04, 95% CI 2.13-47.50 and HR=3.40, 95% CI 1.05-10.99, respectively). In the MEC subset, the associations remained after additional adjustment for BMI (HR=16.30, 95% CI 2.84-93.40 and HR=4.64, 95% CI 1.30-16.59, respectively). IGFBP3 was also associated with a poorer breast cancer-specific survival in Native Hawaiian women when adjusted for age, stage, first-course of treatment, ER, PR, and HER2 (HR=2.79, 95% CI 1.12-6.93), and additional adjustment for BMI (HR=3.03, 95% CI 1.19-7.34). IGF1R expression was significantly inversely associated with overall survival among Native Hawaiians after adjustment for age, stage, first-course of treatment, ER, PR, HER2, and BMI (HR=14.46, 95% CI 2.26-92.57). In the analyses of individual race/ethnic groups, null cell sizes precluded the evaluation of estrogen use as a covariate. Aberrant insulin-signaling may influence outcomes in Native Hawaiian breast cancer patients. Citation Format: Brenda Y. Hernandez, Lynne R. Wilkens, Loic Le Marchand, David Horio, Clayton D. Chong, Lenora W. M. Loo. IGF-axis protein expression and survival in Native Hawaiian breast cancer patients. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3264. doi:10.1158/1538-7445.AM2014-3264

Abstract LB-261: Atopic allergic conditions and colorectal cancer risk in the Multiethnic Cohort

Abstract Previous studies have provided suggestive evidence of an inverse association between atopic allergic conditions (AAC) and colorectal cancer (CRC) incidence and mortality in predominantly White populations. Here we examined the association between AAC and CRC among White, African American, Native Hawaiian, Japanese American, and Latino men and women in the Multiethnic Cohort (MEC). AAC exposure status was ascertained via self-reported physician diagnosis using a baseline 26-page validated questionnaire. The analysis included 4259 incident CRC cases and 1221 CRC-related deaths ascertained between 1993 and 2010. We also examined associations by ethnic group, location, and stage of cancer as well as potential effect modification by CRC risk factors. AAC was associated with a reduced risk of colorectal cancer incidence among both men and women (RR = 0.85, 95% CI 0.79, 0.91, p < 0.0001). The reduction in risk was noted in each population and was significant in Whites (RR = 0.84, 95% CI 0.71, 0.98, p = 0.03), African Americans (RR = 0.81, 95% CI 0.69, 0.95, p = 0.01), and Japanese Americans (RR = 0.85, 95% CI 0.75, 0.97, p = 0.01). Suggestive evidence of effect modification was noted by smoking (p = 0.07) and aspirin use (p = 0.08), with a greater protective effect observed among current smokers (RR = 0.72, 95% CI 0.58, 0.89, p = 0.002) and never users of aspirin (RR = 0.81, 95% CI 0.73, 0.89, p < 0.0001). Individuals with AAC also had a 19% reduction in CRC-related mortality (P = 0.004). Colonoscopy screening is unlikely to explain these inverse associations, as individuals with AAC were more likely to be screened than those without AAC (p < 0.003 for all ethnic groups). These findings provide support for an association between immune pathology and colorectal cancer, potentially through modulation of the immune system's IgE-mediated pathways systemically and within the gut. Citation Format: Neal A. Tambe, Dan O. Stram, Lynne R. Wilkens, Peggy Wan, Frank D. Gilliland, Brian E. Henderson, Loic Le Marchand, Christopher A. Haiman. Atopic allergic conditions and colorectal cancer risk in the Multiethnic Cohort. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr LB-261. doi:10.1158/1538-7445.AM2014-LB-261

Highly effective contraceptive use more likely among native Hawaiian women than non-Hawaiian women at Title X clinics in Hawai‘i

Objectives: Native Hawaiians experience the highest rate of unintended pregnancy in Hawaiʻi. Our study aimed to determine whether Native Hawaiian women using contraceptives were more or less likely to choose a highly effective method than non-Hawaiian women.

Refining the research infrastructure at community health centers.

Community health centers (CHC) often partner with academics to conduct community-based participatory research (CBPR). Because of their research expertise, academic partners are usually the principal investigators (PIs); however, moving the home base of research to the community can prove beneficial to the CHC and its community. The purpose of this paper was to discuss the lessons learned after conducting a CBPR project and to share identified solutions. A longitudinal perinatal risk reduction intervention study was conducted with primiparous Native Hawaiian women receiving prenatal care at a CHC. The intervention incorporated home visiting, social support, and lactation management. Primary lessons learned from this participatory process can be grouped into infrastructure, human resources, and recruitment. Sharing lessons learned can serve to expand a CHC's involvement in research, and provide a venue for discovering innovative and viable community and practice based approaches to solving health disparity challenges.

Cancer Clinical Trials in Hawai‘i: Who’s Being Represented

Background: Representation of diverse ethnic/racial groups is critically important in the development of cancer prevention and treatment strategies. However, representation of diverse ethnic/racial groups has yet to be fully realized, especially among historically disadvantaged minority groups. Ethnic minority groups account for about 75% of Hawai‘i’s population; approximately 55% of the state’s population self-identify as Asian (with the most predominant ethnic/racial groups being Japanese, Filipino, Chinese, and Korean) and approximately 24% as Native Hawaiian/Pacific Islander. Such diversity provided researchers a unique opportunity to characterize the demographic profile of cancer prevention and treatment trials conducted in Hawai ‘i. Methods: In the current study, the gender and ethnic/racial distribution of four national cancer prevention trials and 178 treatment trials conducted in Hawai‘i from 1992 to 2004 were characterized. Results: Native Hawaiian men were significantly less likely to participate in both cancer prevention and treatment trials than Native Hawaiian women. In addition, Native Hawaiian men and women had the lowest proportion of participation in cancer clinical trials in comparison to White and Asian American men and women. Conclusions: Our findings identify gender and ethnic/racial differences in the participation of cancer clinical trial participants in the state of Hawai‘i. This serves as an important indicator for the need of future research to specifically investigate the relationship of culture and other factors on participation. Such research may inform promotional strategies that increase trial participation, with the hopeful prospect of decreasing cancer incidence and increasing quality of life for those diagnosed with cancer.

Alcohol consumption and breast cancer risk among women from five ethnic groups with light to moderate intakes: The Multiethnic Cohort Study

Higher alcohol consumption, even at moderate levels, has been associated with an increased risk of breast cancer in epidemiological studies. However, prior studies were conducted in mostly white populations. To assess the relationship of alcohol consumption to postmenopausal breast cancer risk in a multiethnic population of largely never, light or moderate drinkers, we prospectively examined the association in 85,089 women enrolled in the Multiethnic Cohort in Hawaii and California. During a mean follow-up of 12.4 years, 3,885 incident invasive breast cancer cases were identified. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazard models, controlling for potential confounders. Higher alcohol consumption was associated with increased risk of breast cancer: compared to nondrinkers, HRs were 1.23 (95% CI: 1.06-1.42), 1.21 (95% CI: 1.00-1.45), 1.12 (95% CI: 0.95-1.31) and 1.53 (95% CI: 1.32-1.77) for 5-9.9, 10-14.9, 15-29.9 and ≥ 30 g/day of alcohol, respectively. The positive association was seen in African American, Japanese American, Latino and white, but not in Native Hawaiian women, and in those with tumors that were both positive and negative for estrogen and progesterone receptors (ER/PR). This prospective study supports previous findings that light to moderate alcohol consumption increases breast cancer risk, and demonstrates this association in several ethnic groups besides whites, independent of ER/PR status.