Personal cancer prevention and screening practices among Asian Indian physicians in the United States

Cancer Detection and Prevention 28 (2004) 269–276

Personal cancer prevention and screening practices among Asian Indian physicians in the United States Ranjita Misra, PhD, CHES a,∗ , Susan T. Vadaparampil, PhD, MPH b a

Health and Kinesiology Department, Texas A&M University, 4243 TAMU, 158P Read Building, College Station, TX 77843-4243, USA b Health Outcomes and Behavior Program, Department of Interdisciplinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA Accepted 6 February 2004

Abstract This study examines personal cancer prevention and screening practices of Asian Indian physicians. Asian Indians are the third largest group of Asian Pacific Islanders (APIs) residing in the United States. Using a cross-sectional study approach, we investigated cancer prevention and screening practices of 254 randomly selected Asian Indian physicians in the United States. Results showed that prevalence of conventional risk factors were low, e.g., smoking, alcohol consumption. Nutrition-related behaviors indicated 31–48% met the Food Guide Pyramid’s recommendations for daily intake of fruits, vegetables, low fat/cholesterol diet, and grains. Certain cancer prevention and screening practices failed to meet age appropriate recommendations of leading health agencies. For men age 50 and over, only 27% ever had a flexible sigmoidoscopy and 25% ever had a fecal occult blood test (FOBT); 84% of women age 40 and over ever had a mammogram and 87% of women ever had a Papanicalou (Pap) smear. With respect to cancer screening behaviors, the respondents were less likely to engage in these preventive screenings (with the exception of mammography) than the general US population and the APIs (except Pap smears). Additionally, our respondents were less likely than other physicians to practice cancer screening behaviors. Results support the need to promote regular cancer prevention and screening among Asian Indian physicians. © 2004 International Society for Preventive Oncology. Published by Elsevier Ltd. All rights reserved. Keywords: Asian Indian; Cancer prevention; Cancer screening; Physicians; Asian Pacific Islanders

1. Introduction Asian and Pacific Islanders (APIs) are the fastest growing racial/ethnic group, and one of the largest minority groups in the United States (US). According to the US 2000 Census Bureau’s medium range population projections, APIs will increase by 267% between 1995 and 2050, compared to 35 and 83% projected increases for Whites and African Americans, respectively [1]. The API classification includes individuals who trace their background to the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands [2]. Asian Indians are the third largest and fastest growing API subgroup in the US. With a growth of 106% over the last 10 years, it is estimated that 1,678,765 Asian Indians (16.4% of APIs) reside in the US [1]. As the diversity within the US population continues to increase, it is critical for researchers and practition∗ Corresponding author. Tel.: +1-979-845-8726; fax: +1-979-847-8987. E-mail address: [email protected] (R. Misra).

ers to gain an understanding of health-related beliefs and behaviors in this racial/ethnic group to meet their health care needs. A lack of national data specific to or inclusive of the API population limits knowledge regarding health issues of Asian Indians. Furthermore, the nature and extent of health disparities among the individual groups that comprise the APIs are masked because most research studies look at APIs in the aggregate. For example, while some studies among APIs have shown relatively low rates of coronary heart disease (CHD), research among Asian Indian males has indicated a higher prevalence rate than other APIs, as well as US Black and White males [3–5]. Similarly, within group differences in cancer incidence and cancer mortality rate may be masked when we examine APIs collectively. In a study of APIs by the Illinois Department of Health from 1992 to 1998, stomach cancer was cited as the fifth leading cause of cancer incidence and fourth leading cause of cancer mortality. Stomach cancer was not ranked in the top 10 sites for cancer incidence or

0361-090X/$30.00 © 2004 International Society for Preventive Oncology. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.cdp.2004.02.004

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cancer mortality for Asian Indians [6]. Limited studies indicate that cancer rates are lower among Asian Indians than the US population in general but will increase and attain similar rates as Americans with increasing acculturation, as seen with other API groups, e.g., the Japanese and Chinese [7–9]. For example, comparison of breast and colon cancer incidence rates among Native Asian Indians, US immigrant Asian Indians, and Caucasians showed immigrant Asian Indians had higher risk of developing breast and colon cancer than natives in India [10]. Therefore, it is important to understand cancer prevention and screening behaviors within this group. A major challenge to studying health issues related to Asian Indians is their extreme heterogeneity. They are considered the most diverse among all other ethnic groups originating from a single nation due to their primary languages, provincialism, religious affiliations, and caste system [11]. Hence, sources previously used to obtain Asian Indian study participants such as cultural events or ethnic neighborhoods have yielded samples that are either a culturally, religiously, linguistically, or regionally biased subset of Asian Indians residing in the US [12–16]. In order to obtain a broader sample, we selected participants based on membership in a professional organization of Asian Indian Physicians that is more likely to include individuals that represent different cultures, religions, and languages of India. While this may produce a sample that is potentially biased in terms of socioeconomic status, Asian Indians are a relatively affluent and well-educated minority group. A recent summary of the US 2000 Census data shows that the median income for Asian Indian households is $60,093.00 compared to $41,110 for non-Hispanic white families. Additionally, 67% of foreign-born Asian Indians have greater than a college education, compared to 21% of white Americans [17]. The strategy of using physicians to study personal health behaviors is not new, but rather has been used in the US for many years. These studies have been conducted both on a large scale such as the Physicians’ Health Study and the Women Physicians’ Health Study [18–20] and on a smaller scale with physicians from a particular state, institution, or professional organization [21–25]. Studying personal health habits of this population is useful for a number of reasons. A recent review suggests that physicians who practice health-promoting behaviors are more likely to counsel their patients to also practice these behaviors. Several studies included in the review showed direct relationships between the behaviors physicians practice and the behaviors for which they counsel patients. For example, regular exercisers counseled patients more often on exercise habits and non-smokers counseled patients more often on smoking cessation. This relationship between personal behavior and patient counseling may be due to a feeling by physicians that if they promote healthy habits among their patients, then they should serve as a role model for these behaviors [18].

Evidence also suggests that individuals usually seek care from physicians of their own race and tend to be more satisfied with the health care delivered by physicians who are of the same race [26,27]. If this holds true for Asian Indian patients, Asian Indian physicians may be an important channel to reach this community with cancer prevention and screening messages and interventions. Thus, personal physician behaviors may reflect their knowledge, attitudes, and behaviors related to cancer prevention and screening practices they recommend to their patients. Alternatively, if physicians believe in the value of screening for themselves, they will also see the value to their patients. For either explanation, physician behavior foreshadows physicians’ practice patterns with their patients. Finally, limited studies report that physician health practices tend to be better than the general US population, thus providing a best case scenario to investigate cancer prevention and screening practices [28]. The primary aim of this study is to establish basic demographic information and baseline rates of cancer prevention and screening practices among Asian Indian physicians residing in the US.

2. Methodology 2.1. Sample and data collection The study design is a cross-sectional study of immigrant Asian Indian physicians in the US. A random (nationwide) mail survey was sent to physicians who were members of the American Association of Physicians of Indian origin (AAPI) during the years 1998–2000. This directory was selected because it provided the most comprehensive list of Asian Indian physicians in the United States (the directory currently lists more than 33,000 members). The Ohio University’s Institutional Review Board approved the study and surveys were mailed to 1000 randomly selected physicians (all specializations) with a second mailing of questionnaires sent after 2 weeks to improve the response rate. Data were collected using a self-administered, voluntary, and anonymous questionnaire. 2.2. Instrument As part of a larger study, information was obtained on participants’ demographics (age, gender, education, income, height, weight, and geographic region), cancer preventive health behaviors (diet, physical activity, smoking status, and alcohol consumption), and cancer screening practices (flexible sigmoidoscopy, fecal occult blood test (FOBT), mammography, and Papanicalou (Pap) smears. For the purpose of this study, current smokers were defined as “currently using any number of cigarettes, cigars, chewing tobacco” and for the consumption of alcoholic beverages, a drink was defined as “drinking one can or bottle of beer, one glass of wine, one can or bottle of wine cooler, one cocktail, or one shot of liquor within the past month”. Physical activ-

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ity was defined as “exercising for at least 30 min on 5 or more days per week.” The instrument was pilot tested for response time and clarity with five Asian Indian physicians practicing in Athens, Ohio. The average response time for this 112-question survey was 18 min (range 15–20 min) and a few questions were revised in the survey questionnaire to reduce ambiguity. Many of the questions related to cancer prevention and screening practices were derived from guidelines provided by the United States Department of Agriculture and the American Cancer Society [29,30]. Items were worded in a format similar to that of the Behavioral Risk Factor Surveillance System (BRFSS) [31]. 2.3. Data analysis Basic descriptive statistics including mean ± standard deviation were obtained for age, and number of years living in the US. Frequencies were calculated for categorical variables including marital status, region of residence, prevalence of chronic diseases, and cancer prevention practices. Data analysis was performed using the Statistical Package for Social Science 9.0 software [32]. 3. Results 3.1. Response rate Of the 1000 surveys that were mailed, 320 surveys were returned due to incomplete/change of address. Of the 680 surveys that presumably reached AAPI members, 254 completed questionnaires were returned yielding a final response rate of 37%. Although the response rate might be considered low, it is higher than those reported for Asians in general, and Asian Indians in particular in earlier studies [14,25]. Comparisons of demographic information between the survey participants and non-respondents via the AAPI directory revealed similarities in age, place of residence, medical specialty, and year of medical school graduation, but an under representation of females (27% versus 35%) in our sample. 3.2. Demographic and medical characteristics The average age of the study participants was 50.88 ± 9.76 years, with 94% of the sample currently married. The majority of the respondents were males (72%). Ninety five percent of the physicians in the sample were immigrants that have resided in the US for an average of 23.08 ± 8.85 years. Respondents hailed from numerous regions of India as indicated by the variety of languages that physicians listed as their native tongue including Punjabi, Bengali, Gujarati, Kannada, Malayalam, Marathi, Tamil and Telegu (data not shown). Geographically, 41% of the sample resided in the Northeast, 18% in the South, 32% in the Midwest, and 8% in the West region of the US. There was almost no personal history of cancer among respondents (1%) and only 6 and

271

Table 1 Demographic and medical characteristics of Asian Indian physicians (n = 254) Total (%)

Total n

¯ ± S.D.) Age (X

50.9 ± 9.8

252

2

Gender Male Female

72.4 27.2

184 69

1

Born outside US Yes No

94.9 1.6

241 4

9

23.1 ± 8.9

235

19

Currently married Yes Noa

93.7 6.3

238 16

0

Region of residenceb Northeast South Midwest West

40.9 18.1 31.9 7.9

104 46 81 20

3

Cancer Yes No

0.8 99.2

2 252

0

Hypertension Yes No

16.5 83.5

42 212

0

Diabetes Yes No

6.3 93.7

16 238

0

Heart disease Yes No

4.3 95.7

11 243

0

# Years living in US ¯ S.D.) (X±

Missing responses (n)

Percentages may not add up to 100% due to missing data or rounding error. a Includes separated, divorced, widowed, and never married. b Northeast: CT, ME, MA, NH, NJ, NY, PA, RI, VT; midwest: IL, IN, IA, KS, MI, MN, NE, ND, OH, SD, WI; south: AL, AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV; and west: AK, AZ, CA, CO, HI, ID, MT, NV, NM, OR.

4% of respondents reported a personal history of diabetes and heart disease, respectively. Seventeen percent reported a personal history of hypertension (Table 1). 3.3. Cancer prevention practices With respect to fruit and vegetable consumption, 31% of our sample reported ‘always’ eating two to four servings of fruits a day, 45% reported ‘sometimes’ eating two to four servings of fruits a day, and the remaining individuals never or rarely consumed fruits in these quantities. Forty eight percent of respondents reported always eating three to five servings of vegetables a day, 39% sometimes, and 8% either rarely or never. In terms of consuming 6–11 servings of grains daily, 35% reported always doing so, 34% sometimes,

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Table 2 Cancer prevention practices of Asian Indian physicians (n = 254) American Cancer Society guidelines 2–4 servings of fruit/day Always Sometimes Rarely Never

Total (%)a

Total n

Missing responses (n)

31 45 19 3

78 114 47 7

8

3–5 servings of vegetables/day Always 48 Sometimes 39 Rarely 6 Never 2

122 99 16 4

13

6–11 servings of breads, pastas, grains/day Always 35 Sometimes 34 Rarely 15 Never 9

88 85 37 24

Eat foods low in fat, saturated fat, cholesterol Always 41 104 Sometimes 43 110 Rarely 6 14 Never 2 4 During the past month had at least 1 alcoholic drink Yes 56 143 No 39 100

Table 3 Age specific cancer screening practices among Asian Indian physicians Total (%)a Ever had Yes No

sigmoidoscopyb

22

11

Moderately physically active ≥30 min on ≥5 days a week Yes 34 85 56 No 45 113 Healthy weight range BMI ≤25.0 25.1–29.9 ≥30

63 32 4

159 82 9

4

Use tobacco products Yes No

3 91

9 231

14

a

Percentages may not add up to 100% due to missing data or rounding error.

and 25% rarely or never. Most of the respondents reported they always (41%) or sometimes (43%) eat foods low in fat, saturated fat, and cholesterol and only 8% responded they rarely or never do so. The majority of the sample (56%) reported having at least one alcoholic drink in the previous month. Thirty four percent of our sample reported being physically active (defined as exercising for at least 30 min on 5 or more days per week). Over 60% of the sample had a body mass index (BMI) that is in a range reported to promote optimal health (BMI = 18.5–25.0) [33]. Tobacco use among this group was rare with 91% indicating that they do not use tobacco products (Table 2). 3.4. Cancer screening practices There is currently no uniform set of cancer screening guidelines supported by all leading health agencies with respect to type, age of initiation, frequency, and effectiveness

Missing responses (n)

40 85

26

37 86

28

(≥50)

27 56

Ever had FOBTb (≥50) Yes 25 No 57

20

Total n

Ever had a mammogramc (≥40) Yes 84 52 No 8 5

5

Ever had a Pap smeard (≥18) Yes 87 No 4

6

60 3

a Percentages may not add up to 100% due to missing data or rounding error. b Included men and women age 50 and over (n = 151). c Included women age 40 and over (n = 62). d Included all women (n = 69).

[34]. However, there is general agreement that the following screenings should be done: FOBT and flexible sigmoidoscopy every 3–5 years for men and women age 50 and over for early detection of colon cancer, annual Pap tests for women age 18 and older for early detection of cervical cancer, and annual mammography for women age 40 and over for early detection of breast cancer [34]. Based upon these guidelines, we included men and women age 50 and above (n = 151) for analyses related to colon cancer screenings (FOBT and flexible sigmoidoscopy). For analyses related to Pap smear we included all women (n = 69) and women age 40 and over for mammography (n = 62). Overall, results indicate that only 27% of the sample age 50 and over ever had a flexible sigmoidoscopy and 25% ever had a FOBT. Approximately 87% of the females reported ever having a Pap smear and 84% of female physicians over the age of 40 reported ever having a mammogram (Table 3).

4. Discussion The primary purpose of this study was to establish cancer screening and prevention practices among Asian Indian physicians residing in the US. We compared our study results with the API population and the general US population. Where data were available, we also compared our results to other physicians. Dietary intake of fruits and vegetables, starch, and fat/cholesterol among immigrant Asian Indians in the US and the Asian Indian physicians from this study are difficult to compare due to differing instruments used to solicit information. However, prior reports of Asian Indian diet show consumption lower than the daily recommended value recommendation of 300 g of carbohydrates and higher than the recommended rate of 30% of total calories from fat [25,35].

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273

Table 4 Comparison of selected cancer prevention practice rates among Asian Indian physicians, Asian Pacific Islanders residing in the US, and the general US population Behavior

Asian Indian physicians (%)a

Asian Pacific Islanders (%)b

General US population (%)c

Fruit and vegetable Consumption Physical activity BMI ≥ 25.0 Tobacco use Alcohol consumption

26 34 36 3 56

NAd 32 NAd 15 NAd

37 32 42 23 54

a

Fruit and vegetable consumption: reporting always eating 2–4 servings of fruit a day and eating 3–5 servings of vegetables a day; physical activity: exercising for at least 30 min on 5 or more days per week; tobacco use: currently use tobacco products; alcohol consumption: having at least one alcoholic drink in the previous month. b Physical activity: reporting at least light or moderate physical activity for at least 30 min, five or more times a week [36]; tobacco use: persons who reported having smoked at least 100 or more cigarettes during their lifetime and who reported at the time of the interview smoking everyday or some days [29]. c Fruit and vegetable consumption: reporting five times a day as average frequency of fruit and vegetable consumption in a day [31]; physical activity: reporting at least light or moderate physical activity for at least 30 min, five or more times a week [29]; tobacco use: currently using cigarettes [31]; alcohol consumption: had at least one drink of any alcoholic beverage during the previous month [31]. d Data not available.

As shown in Table 4, a lower percentage of Asian Indian physicians in this sample met the Food Guide Pyramid’s recommendations for daily servings of fruits and vegetables per day as compared to the general population [30]. Rates of physical activity were higher than the 2000 National Health Interview Survey (NHIS) age adjusted data for the general US population [29] and APIs [36] for moderate and/or vigorous physical activity. This finding was higher than a previous study of Asian Indian physicians who reported an average of 136 min of leisure time activity a week (resulting in less than 30 min/day of physical activity 5 days a week which was used as the criteria for moderate physical activity in our study) [25]. Rates of tobacco use have been shown to be lower among Asian Indians compared to other ethnic groups [4,37,38], and our results support this finding. The rate of current smoking among the Asian Indian physicians was lower than earlier reports on Asian Indians [38] as well as the general US

population [31] and may be attributed to respondents being health care providers. However, this does not provide a complete explanation. Earlier studies reported 16% of male members of a California medical society and 4% of female physicians in the Women Physician’s Health Study were current smokers [28]. Other factors that may contribute to the low smoking prevalence in this sample could be cultural ones, i.e., smoking among women is less tolerable, and tobacco products more commonly used by men in India, such as bettle quid chewing and Indian cigarettes known as bidis, are less available in the US [38]. Other potential risk factors for cancer such as alcohol consumption and obesity were present in rates similar (alcohol) or slightly lower (obesity) than that of the general US population [31]. As shown in Table 5, with the exception of mammography, physicians in our sample had lower rates of cancer screenings when compared to the general US population and APIs. To our knowledge, there is no available data regard-

Table 5 Comparison of cancer screening rates among Asian Indian Physicians, Asian Pacific Islanders residing in the US, and the general US population Screening

Asian Indian physicians (%)a

Hopkins Cohort (%)b

Women Physician’s Health Study (%)c

Asian Pacific Islanders (%)d

General US population (%)e

Sigmoidoscopy FOBT Mammogram Pap smear

27 25 84 87

44 57 74 NAf

43 75 98 99

31 34 86 76

37 35 62 93

a

Sigmoidocscopy: age >50 reporting ever had sigmoidoscopy; FOBT: age >50 reporting ever had FOBT; mammogram: females age >40 reporting ever had mammogram; Pap smear: females ≥30 reporting ever had Pap smear. b Sigmoidoscopy: age ≥50 reporting either colonoscopy or barium enema within the past 5 years; FOBT: age ≥50 reporting FOBT within the past 2 years; mammography: females age ≥52 reporting mammogram within the past 2 years [24]. c Sigmoidocscopy: females age 50–70 reporting ever had sigmoidoscopy; FOBT: females age 50–70 reporting ever had FOBT; mammography: females age 50–70 reporting ever had mammogram; Pap smear: female physicians age ≥30 reporting ever had Pap smear [28]. d Sigmoidoscopy: Asian Pacific Islanders age ≥50 reporting ever had sigmoidoscopy in 1998 NHIS [29]; FOBT: Asian Pacific Islanders age ≥50 reporting ever had FOBT in 1998 NHIS [29]; mammography: females age >40 reporting ever had mammogram in 2000 BRFSS [31]; Pap smear: Asian Pacific Islander females age >18 reporting ever had Pap smear in 1999 [36]. e Sigmoidocscopy: age >50 reporting ever had sigmoidoscopy in 1998 [29]; FOBT: age >50 reporting ever had FOBT in 1998 [29]; mammogram: females age >40 reporting ever had mammogram in 1997 [47]; Pap smear: females ≥18 reporting ever had Pap smear in 1997. f National data not available.

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ing the use of colon cancer screening among Asian Indians. The rates of ever having a sigmoidoscopy and FOBT among Asian Indian physicians were lower than all of our comparison groups. In our study 27% of participants reported ever having a sigmoidoscopy and 25% reported ever having an FOBT compared to ≥30% in the general US population and APIs [29]. In a study of 915 physicians who were followed in a cohort study of graduates of the Johns Hopkins School of Medicine from 1948 through 1964, 44% of the sample reported either having a colonoscopy or barium enema within the previous 5 years and 57% reported having an FOBT in the past 2 years [24]. In the Women Physicians’ Health Study (WPHS), of the 4501 female US physicians, 43 and 75% of respondents age 50–70 reported ever having a sigmoidoscopy and FOBT, respectively [28]. While rates of ever having a mammogram were higher among female Asian Indian physicians (84%) than the general US population (62%), rates were lower than both APIs (86%) and physicians participating in the WPHS (98%). Compared to smaller studies of Asian Indian women, the rates of having a mammogram were substantially higher. Previous studies looking at Asian Indian women reported the rate of mammography to be between 58 and 60% [12,15,16]. Our sample is likely to have less of the barriers reported by those studies such as language problems, lack of health insurance, or inadequate knowledge of mammography [15,16]. Reports of ever having a Pap smear in our sample (87%) were lower than the general US population (93%), but higher than APIs as a whole (76%). However, when compared to female physicians as a whole (99%), the rates of ever having a Pap smear were much lower. Lack of screening adherence among Asian Indian female physicians may be due to a decreased family history of cancer among Asian Indians resulting in a lack of perceived risk [35]. Additionally, less emphasis on preventive health services and use of alternative forms of medicine (e.g., homeopathy and herbal medicine) may result in decreased use of prevention and screening practices, even among individuals with western medical training and health insurance coverage [39–41]. Since physicians are a highly educated and informed group, and a professional segment of the Asian Indian population, they provide the “best case scenario” for the immigrant Asian Indians in the US. Often cited socioeconomic barriers to cancer prevention and screening practices such as education and income are generally not factors in this group. While as a whole our respondents fare better when compared to the general population, the same does not hold true when compared to other physicians, a cohort more likely to have similar socioeconomic characteristics. Hence the results underscore the importance of cancer education for Asian Indian physicians and potentially for Asian Indians in the US. To our knowledge, with the exception of mammography, there is currently no information on cancer prevention and screening practices among Asian Indians such as Pap smears, FOBT, or sigmoidoscopy.

The findings of this study provide baseline information on cancer screening practices among Asian Indian physicians in the United States. However, results of this study should be considered in context, and not be generalized to all Asian Indian physicians and Asian Indians without further investigations. For example, a recent study of female physicians in the US indicates that they generally have better health habits when compared to women in the general population of similar socioeconomic status [28]. Conclusions from this study must be drawn with caution. This report was based solely on self-reports, and the response rate was low despite the use of survey methods that traditionally bolster response rates, e.g., a quick succession second mailing. The low response rate might be due to several reasons: length of the survey (10 pages), busy work schedule of physicians, and incorrect or incomplete address information. Problems with non-response to surveys have been previously reported for the Asian population in general [42]. However, the response rate was slightly higher than prior studies on Asian Indians in the US [14]. A final limitation was measuring all cancer screenings using ‘ever/never’ response categories rather than age appropriate adherence patterns [29]. Despite phrasing questions in formats similar to that of national health surveys, we were unable to compare our results due to a paucity of information on cancer prevention practices at the national level on the APIs in general and much less on Asian Indians in particular. This study serves as an important first step for identifying priority or problem areas within this group. Future studies are recommended at the community level to determine whether the rates of cancer prevention and screening practices found in our study are also found among Asian Indians in general. With the information gained from these studies, interventions can be designed to reduce barriers and increase cancer prevention and screening behaviors for this population.

5. Conclusions and recommendations This report provides insight into cancer prevention and screening practices among Asian Indian physicians in the US. Despite their higher socioeconomic level and knowledge of cancer prevention and screening practices, results showed that the majority of respondents did not meet the Surgeon’s General’s recommendation for physical activity and the Food Guide Pyramid’s recommendations for daily consumption of fruits, vegetables, low fat/cholesterol diet, and grains. Some of the conventional risk factors for cancer, e.g., use of tobacco products and alcohol were lower in this sample. With respect to cancer screening behaviors, the respondents were less likely to engage in these preventive screenings (except mammography) than the general US population and API (except Pap smears). However, our respondents were less likely than other physicians to practice cancer screening behaviors and suggest a need for improve-

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ment in primary and secondary prevention of cancer among the Asian Indian physicians. There is an image of Asian Americans as a “model minority” who have overcome their “ethnic handicap” and are socio-economically well off [2,43,44]. However, the health needs in general, and specifically to cancer, have been overlooked in this group [45]. The Asian Indian population in the US is still relatively young in its age structure. Even though the majority of respondents have lived in the US for more than two decades, lack of emphasis on preventive health behaviors may have resulted in lower health promotive behaviors [46]. However, if Asian Indians follow the same patterns of increased cancer rates with increasing acculturation, there is a need to target lifestyle changes through public health education. Furthermore, additional investigations replicating and extending this research are vital for ensuring disease prevention and health promotion efforts among the Asian Indian population in the US.

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