Disaggregating cancer risk among Asian American and Pacific Islander solid organ transplant recipients
Year: 2025
Type: editorial
Abstract: Solid organ transplantation has emerged as a well-established and life-saving treatment option for patients with end-stage organ diseases. This process involves the identification of a suitable transplant donor and the use of lifelong immunosuppression to minimize the risk of graft rejection. However, prolonged immunosuppression increases the risk of viral infections and the subsequent onset of virus-mediated malignancies due to the prevention of tumor clearance and immune control. For instance, Epstein-Barr virus–associated Hodgkin and non-Hodgkin lymphoma, human papillomavirus–associated anogenital cancers, and herpesvirus-associated Kaposi sarcoma have historically occurred at elevated rates among solid organ transplant recipients.1 Asian Americans and Pacific Islanders have historically experienced high rates of cancer morbidity and mortality, with cancer representing the leading cause of death in Chinese, Filipino, Korean, and Vietnamese American people.2 Native Hawaiian and Pacific Islander people have 2 to 3 times higher rates of mortality from cervical, stomach, and endometrial cancers compared with non-Hispanic White people. Some virus-mediated cancers, such as nasopharyngeal cancer, present at rates 7 times higher among Asian Americans and Pacific Islanders than among non-Hispanic White Americans, with rates up to 14 times and 10 times higher among Laotian Americans and Chinese Americans, respectively, compared with non-Hispanic White Americans.3-5 Given these salient differences in cancer risk, in this issue of the Journal, Tao et al.6 sought to explore the link between solid organ transplant recipient status as a risk factor for elevated cancer incidence among Asian American and Pacific Islander populations. Specifically, this retrospective observational cohort study evaluated rates of cancer incidence among Asian American and Pacific Islander solid organ transplant recipients compared with nonrecipients and non-Hispanic White populations, disaggregated by ancestry and cancer subtype. The study used the US Scientific Registry of Transplant Recipients database, which consists of 34 population-based cancer registries from which the authors extracted data on cancer cases among solid organ transplant recipients for Asian American, Pacific Islander, and White populations. The authors calculated incidence rates for each cancer subtype, disaggregated by Asian American, Pacific Islander, or non-Hispanic White populations, and found striking variation both by cancer type and by racial and ethnic group. For instance, concordant with existing data, incidence rates of nasopharyngeal carcinoma, renal pelvis cancer, stomach cancer, and thyroid cancer were higher among Asian Americans than among non-Hispanic White Americans. When considering the excess risk induced by solid organ transplant recipient status, the authors found that Asian American solid organ transplant recipients had an incidence rate ratio of 15 for Kaposi sarcoma; 13 for lip cancer; 9.8 for nonepithelial skin cancer; 8.9 for penile cancer; 7.9 for anal cancer; and more than 5 for renal pelvis cancer, Hodgkin lymphoma, and kidney cancer compared with Asian American non–solid organ transplant recipients. A similar trend held for Pacific Islander solid organ transplant recipients, who had an incidence rate ratio of 71 and 12 for Kaposi sarcoma and anal cancer, respectively, compared with Pacific Islander non–solid organ transplant recipients. These results demonstrate that disaggregation of Asian American and Pacific Islander subgroups and cancer subtypes reveals otherwise-masked intergroup disparities. A growing body of evidence has suggested that Asian American and Pacific Islander populations have statistically significant intergroup differences in cancer risks and health outcomes that are masked upon aggregation. For instance, aggregation of Asian American and Pacific Islander populations have masked disparities in breast cancer, colon cancer, nasopharynx cancer, and more, where there exists major differences in disease stage at presentation between these 2 groups.4,7,8 Such disparities can be traced back to social determinants of health, where differing cultures, languages, and immigration histories of Asian American vs Pacific Islander people manifest in disparities in insurance coverage, rates of cancer screening, and financial toxicity.9-12 For instance, in 2022, 12.4% of older non-Hispanic Pacific Islanders were uninsured compared with 7.4% of Koreans and 3.6% of Japanese.9 Such social determinants of health disparities could be associated with pretransplant risk factors such as differing rates of comorbid infections and could also contribute to inequities in access to post-transplant care. Given the elevated cancer risk profiles of solid organ transplant recipients and the substantial within-group disparities Asian American and Pacific Islander patients face, further research must disaggregate Asian Americans and Pacific Islanders into more granular subtypes. Cancer disparities exist not only between Asian American vs Pacific Islander populations but also within each group. For instance, Samoan men are 8 times more likely to develop liver cancer, Samoan women are twice as likely to be diagnosed with cervical cancer, and Native Hawaiian men are twice as likely to be diagnosed with liver cancer compared with non-Hispanic White Americans.13 Cancer disparities are similarly pronounced within Asian American subgroups: Laotian and Cambodian patients have colorectal cancer 5-year survival rates of 50% and 48%, respectively, compared with 65% for non-Hispanic White patients; Hmong patients have a 40% 5-year average survival rate for all cancers compared with 69% for non-Hispanic White patients.2 Hence, future research must further disaggregate solid organ transplant recipient cancer data by specific ethnicities or countries of origin within the broader Asian American and Pacific Islander groups, such as at a similar level of granularity as the National Cancer Database. Such data would allow for the identification of specific racial and ethnic groups with markedly higher cancer risk among solid organ transplant recipients and, importantly, may shed light on the mechanisms underlying differences in cancer risk. Such insights may widen our understanding of risk factors more common in certain groups and carry broader implications for solid organ transplant recipients. In addition, the detailed analysis by Tao et al.6 of specific cancer subtypes highlights particular high-risk cancers among Asian American and Pacific Islander solid organ transplant recipients, indicating a critical need for targeted interventions. Elevated incidence rates of virus-associated malignancies, such as Kaposi sarcoma, alongside cancers not directly linked to viruses—including thyroid, pancreatic, and kidney cancers—suggest the involvement of factors beyond just immunosuppressive therapies in shaping these disparities. Tao et al.6 incorporated disaggregated data by cancer type, which enables precise, cancer-specific strategies that directly address underlying causes that are likely to yield greater effectiveness compared with broad, one-size-fits-all approaches. For instance, adjustments to postoperative immunosuppression protocols, such as incorporating regular viral screenings and prophylactic antiviral treatments when necessary or promoting culturally informed dietary and lifestyle modifications for patients at higher risk of lifestyle-associated cancers, hold great potential for improving outcomes among Asian American and Pacific Islander solid organ transplant recipients. To combat disparities in cancer outcomes among Asian American and Pacific Islander solid organ transplant recipients, the development of targeted cancer screening protocols is essential. However, there remains a lack of randomized clinical trials examining cancer risk and no clear consensus on appropriate screening strategies for this high-risk group.14 These gaps are particularly concerning given that Asian American and Pacific Islander patients historically demonstrate low rates of cancer screening in the general population.10 To address this situation, future research must establish evidence-based screening guidelines for solid organ transplant recipients that consider the structural screening barriers Asian American and Pacific Islander communities face. Studies have identified several contributing factors to underscreening, including lower rates of clinician recommendation, limited access to health information, and cultural perceptions that certain screenings—such as those for prostate or breast cancer—may conflict with values in some Asian American and Pacific Islander communities related to masculinity or modesty.10,15 Hence, the establishment of cancer screening guidelines for solid organ transplant recipients must be accompanied by inclusive interventions to improve awareness and uptake of cancer screening in disaggregated Asian American and Pacific Islander communities, drawing inspiration from previous successful case studies. For instance, a multifaceted colorectal screening intervention incorporating educational resources, health system navigation, and fecal immunochemical tests in the Philadelphia–New Jersey Korean community disseminated in both Korean and English led to a 16% increase in cancer screening rates.16 Ultimately, the findings of Tao et al.6 underscore the critical need to further disaggregate cancer risks and outcomes among Asian American and Pacific Islander solid organ transplant recipients to characterize intragroup and intergroup disparities. Although Tao et al. provide crucial insights into the elevated risks Asian American and Pacific Islander solid organ transplant recipients face for disaggregated cancer subtypes, data availability has restricted the analysis from identifying cancer risks at the specific country-of-origin level. By promoting detailed, granular ethnic and subtype disaggregation, future research can more accurately capture disparities among these diverse groups. Such work may more precisely guide the development, evaluation, and implementation of screening interventions and improve cancer outcomes for Asian American and Pacific Islander populations. The funder had no role in the writing of this editorial. Stephanie Wang, BAc (Conceptualization, Writing—original draft, Writing—review & editing), Khushi Kohli, BAc (Conceptualization, Writing—review & editing), Isaac Alty, MD (Conceptualization, Writing—review & editing), Edward Christopher Dee, MD (Conceptualization, Funding acquisition, Resources, Supervision, Writing—review & editing). E.C.D. is funded in part through the Prostate Cancer Foundation Young Investigator Award and through the Cancer Center Support Grant from the National Cancer Institute (P30 CA008748). The authors report no conflicts of interest. No new data were generated or analyzed for this editorial.
DOI: 10.1093/jnci/djaf092
Language: English
Subfield: Oncology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4410139465