Like so many medical challenges, breast cancer research reveals a long list of questions. What elements of our environment are carcinogenic? What role do factors like age, diet, and genetics play? And because cancer is biological in nature, many of us tend to think about the individual and their body as an obvious point of focus. What about, though, the larger, societal picture?
That’s what Dr. Scarlett Gomez and the field of social epidemiology are working to uncover. Dr. Gomez and her team have taken data showing that breast cancer risk in Asian Americans in the San Francisco Bay Area is rapidly rising to uncover structural and social determinants that influence that risk. And while Dr. Gomez’s work focuses on Asian American and Pacific Islander populations, that group includes people from 30 to 40 countries—each with different variables and risk factors to consider.
Dr. Gomez is professor and vice chair for faculty development in the Department of Epidemiology and Biostatistics and co-leader of the Cancer Control Program of the Helen Diller Family Comprehensive Cancer Center at the University of California, San Francisco. A BCRF investigator since 2022, Dr. Gomez’s grant is supported by The Estée Lauder Companies’ Travel Retail Award.
Chris Riback: Dr. Gomez, thanks for joining me. I really appreciate your time.
Dr. Scarlett Gomez: Hi Chris. Thanks for the opportunity.
Chris Riback: So I think to understand this conversation and your, we should start at the core, or at least what I believe is the core of what you do for a living. What is epidemiology?
Dr. Scarlett Gomez: The million-dollar question. I would say if you had asked me that maybe 20 years ago or even 10 years ago, most people probably wouldn’t know. But I think with the very obvious global health issue we’ve been dealing with over the past three or so years, I think the field of epidemiology has become much more apparent to the general public. So broadly speaking, epidemiology refers to the study of disease, causes of disease, and its distribution within the population. I am classically trained as an epidemiologist, specifically cancer and other chronic diseases. And I’d love to talk to you in more detail about why cancer surveillance is actually such a unique activity. It’s the only chronic disease for which we collect population level information from everybody who’s been diagnosed with cancer. So we conduct studies to [look at] how cancer occurs within population groups with a strong focus on disparities within particular groups. And we also conduct studies to try to identify risk factors for higher rates in certain groups as well as factors that contribute to worse prognosis.
Chris Riback: So I was going to ask you about that. If your focus always was cancer, and I guess it sounds like it was, and so that makes me wonder why, what attracted you to that area of the discipline?
Dr. Scarlett Gomez: Lots of reasons really. I think like many of us who have been focused on this, on cancer and trying to address this problem of cancer in our society, we come from a place with having had personal experience with cancer. So I think, again, like many, it is a fairly common problem. So I have seen family members, friends who have been diagnosed with the disease, who have struggled with the disease. So from that, a personal interest in trying to understand the structural and social drivers of why cancer may occur more in some populations than others. I have always been drawn to the field of what’s called social epidemiology. Despite that I didn’t know that there was such a field of social epidemiology when I first learned about the idea that societal factors can impact upon disease, and understanding what those associations and patterns may be can help us to design potentially more effective interventions that alleviate disparities in cancer in different populations.
I started out my research career working in a very different field within a pharmaceutical company doing bioanalysis and metabolism research. How drugs are metabolized as [they] move through the body, and it just didn’t feel particularly rewarding because I felt that there was something bigger at the population level that I could be doing. And this was actually before I even knew about the term epidemiology, and that it was actually a field of study. So I took a break and I studied, I embarked on a master’s program in public health where I focused on epidemiology.
And there was at the opportunity to train under Dr. David Schottenfeld, who literally wrote the book on cancer epidemiology. He and Dr. Joe Fraumeni authored. I think they’re now on the sixth edition of the book called Cancer Epidemiology. And that really started cementing my interests and bringing together my personal interest and personal desires to want to understand in particular what we can really do in a meaningful way to address the disparate burden of disease in different populations.
Following that exposure, I had the opportunity to do an internship at a nonprofit organization called at the time Northern California Cancer Center, which then changed its name to Cancer Prevention Institute of California. And I ended up working there for the next 25 years until I moved to my current role here at UCSF about six years ago.
Chris Riback: What an incredible and fortunate thing to have an interest and skills combined and then to be able to make a transition like that. So many of us end up in one role and sometimes feel, and I’m not just talking medicine here, obviously any role, any profession, and one can start to feel like, “Well, I chose the wrong path finding a way out becomes difficult.” I strongly believe one makes one’s own luck, so I don’t characterize it as lucky. I’m sure it was your own initiative, but what a fortunate and excellent thing to get to make a shift like that.
Dr. Scarlett Gomez: It absolutely was luck and in fact, it was really one individual at this pharmaceutical company that I had worked at. He was my informal mentor. We would be pipetting side by side along our lab bench and he would just tell me stories about the six years that he worked in the Peace Corps in rural mountainous Nepal and all the public health and hygiene issues that the populations there had to deal with. And that was when I thought, “Maybe there is a field of study that deals with these issues and its impact on health.” And I think the other way that I was able to marry those interests was in my undergraduate training, even though I was on this straight and narrow path.
Chris Riback: Molecular and cell biology, if I recall, is that right?
Dr. Scarlett Gomez: Molecular and cell biology, because I thought that’s what you needed to major in if you wanted to eventually go to medical school. But I also took a lot of classes in anthropology and social sciences and behavioral health, and I think that actually has been a really good critical foundation for the work that I do today.
Chris Riback: Well, shout out to your former lab partner or pipetting partner.
Dr. Scarlett Gomez: Larry Bowen was his name, I still remember.
Chris Riback: Shout out to Larry. Dr. Gomez, let’s talk about your current research. How and when did you learn that breast cancer risk in Asian Americans in the San Francisco Bay area is rapidly increasing?
Dr. Scarlett Gomez: Yes. So it’s essentially something that our group has been keeping an eye on for quite some time. So, this internship that I had the opportunity to do when I was working on my master’s degree in public health was at this organization that actually ran the cancer registry for the San Francisco Bay Area. Cancer, as many people may know, is a state-mandated activity. Every state, in addition to every Canadian province, has some law that mandates its collection. So if you’re a healthcare clinician provider who’s recently diagnosed or treated somebody with cancer, you are required by your state’s law to report that to your cancer registry. So I was involved and gained exposure to the cancer registry in the Greater Bay area. Much of the funding for our registry actually comes from the NCI (National Cancer Institute) as well as the State Department of Public Health.
So you can imagine what a rich resource of data that is because it is effectively every single person diagnosed with cancer in a defined attachment area. And that is what allows us to track what’s going on in cancer occurrence by different population groups. It’s also the data we use for what we call cancer cluster investigations. So the CDC also invests money into these states and regional cancer registries. So every year we undertake a thorough investigation, a deep dive into the data in our registry to look and see for whom is what’s going on with cancer in our different regions, in our different geographies and our different population groups defined by sex, race, ethnicity, age, et cetera.
And it’s through these kinds of routine surveillance activities that we started to see an interesting shift in breast cancer patterns by race and ethnicity groups in our area such that despite that breast cancer rates have been generally going down over the past about 10 or so years across almost all of our racial ethnic groups. An exception to this would be among African American women where we have been seeing a slight increase. Among Asian American women that’s actually has been rapidly increasing. So, we’re seeing something closer to at least a 10 percent increase in the incidence of breast cancer per year.
Chris Riback: Per year?
Dr. Scarlett Gomez: Yes, per year, about 10 percent increase in breast cancer.
Chris Riback: When did the curve start to shift?
Dr. Scarlett Gomez: I would say it probably started in the 2000s.
Chris Riback: 10 percent a year for a good 15-ish, 20-ish years?
Dr. Scarlett Gomez: Yes.
Chris Riback: That’s a big deal.
Dr. Scarlett Gomez: It is a big deal. I feel that this trend does not tend to get as much attention in large part because we don’t commonly report on cancer rates among Asian American populations are often combined collectively as a group, Asian American, Native Hawaiian, Pacific Islander populations, or AAPIs. When in fact these, if you consider the AAPI or API population, that represents people from 30 to 40 different countries, over 100 different languages. [It’s] highly, highly diverse. And when we start to disaggregate the data, we actually see very divergent patterns. So we’ve done a lot of work just looking within our cancer registry data to see which Asian American, Native Hawaiian, Pacific Islander groups are seeing increasing rates of breast cancer. We actually noted that it’s rapidly increasing nearly all with the interesting exception of Japanese Americans who have been here much longer than other Asian American groups.
And the other interesting finding that has been starting to emerge is that when we look at international data, so breast cancer rates in Asian countries, we’re seeing similar increases. So, it’s really not unique to Asian Americans here in the US—it’s really happening worldwide. The other interesting pattern that we’ve noted is that whereas we are used to the traditional what’s called the migrant paradigm of Asians who come from Asia, their risk is low because risk tends to be lower in Asian countries. And as they start to adopt more westernized health behaviors that are now correlated with increased breast cancer risk, their risk start starts to go up. So we see increasing risk with subsequent generations of Asian Americans.
One recent study that we did showed that, that was reverse in the Bay Area. So in fact in this particular study, we saw higher risk of breast cancer among foreign-born Asian Americans relative to their US-born counterparts. And this was not explained by the known risk factors for breast cancer. When we thought about that pattern, firstly we thought there must be something wrong with our study. We did it wrong. But when you consider the international data, the fact that breast cancer rates have been increasing really rapidly in certain Asian countries to the point that it’s projected that breast cancer in Asia will likely surpass become among the highest in the world.
So the studies in Asia have actually documented and shown that given the rapidly increasing rates of breast cancer that they’ve been seeing, these are studies that have been done with data from Taiwan, Hong Kong, Korea, Singapore, parts of China, that soon we will actually see the highest breast cancer rates among Asian women in Asia. So when we consider that vis-a-vis what we saw with this flip of breast cancer risk comparing foreign-born to U.S. foreign women in the San Francisco Bay Area, it made sense because when we consider who’s been immigrating to the Bay Area over the past 10, 20 years, they have tended to be professionals, particularly those in the tech sector, those in the health sector.
And also when you think about the high costs of living in the San Francisco Bay area, who can really afford to live here and settle here, and in fact some demographic data have documented that when you look at the most recent waves of immigrants, they have tended to have much higher levels of education than prior waves of immigrants. So that all plays into what we’re seeing in terms of rates of breast cancer and these highly dynamic populations like migrant populations in the U.S. So, we think that to the extent that we still have much to learn about what causes breast cancer, both genetically and from a risk factor standpoint, focusing studies on these highly dynamic heterogeneous populations could potentially teach us something about what some of these risk factors might be.
Chris Riback: So you might have just answered what I was going to ask, which is what are you proposing to study? What’s your hypothesis and how will you proceed?
Dr. Scarlett Gomez: Yes. We’re super excited because I think this support from the Breast Cancer Research Foundation, it really gives us the opportunity to do something to focus on this area that we, I think, may not have been able to focus on with more traditional streams of funding. So we are proposing and we are conducting what’s called a case-control study of breast cancer. This means that we are collecting information from women recently diagnosed with breast cancer, specifically Asian American women from a defined catchment area. Here, we’re starting with the Bay Area in addition to we’re expanding to LA, Southern California, and we will also recruit and collect information from matched controls—that is, Asian American women from the same regions, but without prior diagnosis of breast cancer. And by collecting information regarding their past exposures in addition to samples that will allow us to look at some genetic and molecular factors, then we can compare and see which factors are we seeing higher levels of among the cases compared to the controls.
Importantly, the way that we’re doing this study is that we’re recruiting through these cancer registries. So our sampling base is then everybody who’s been diagnosed with breast cancer within a particular defined geographic area. So that from an epidemiologic study design standpoint minimizes bias where asked if you were to recruit, for example, from one healthcare institution, patients from that given healthcare institution may be different and not represent the overall population. We hope that this will be, once women are recruited into this study, they will remain engaged and hopefully provide an opportunity for us to go back to them over time to collect additional information as the study involves and as perhaps emerging hypotheses might come out. But initially, we’re really interested in exploring hypotheses related to stress. Even just this morning, I was talking to a colleague again who had a personal struggle with breast cancer and she herself is a cancer epidemiologist, and she said, “I’m convinced that stress cause my breast cancer.”
And that’s probably the most common thing we hear from patients when we have an opportunity to talk with patients, but we don’t have good evidence. I mean, it’s been scattered and mixed in terms of what we know about stress and its impact on breast cancer risk. And to the extent that some of our Asian American communities have faced historically tremendous trauma relating to their migration experience, relating to the reasons for immigration, relating to settling into a completely new life in a different country for which they don’t speak the language, and acclimating, in addition to recent experiences with discrimination and structural racism as a result of the COVID pandemic. I think that has been understudied area, but potentially could give us some insights into the role of stress and stressors, coping resiliency as it potentially relates to breast cancer risk.
Chris Riback: And this obviously is, well, and I would assume this is out of scope, but a question that comes to my mind would be comparison to other immigrant groups, but maybe you answered that in the first place by saying, well, it’s the Asian American data that has grown so rapidly, 10 percent a year for the last 15, 20 years that’s why that’s a group of interest. We’re not seeing that with other groups. Am I both asking and answering my own question?
Dr. Scarlett Gomez: Well, I think the increase is a motivation for us to be focusing on this particular population because it’s something that’s happening, has been happening, is continuing to happen, and we need to understand why. At the same time, from a data standpoint, when you see such dynamic changes like that, it provides statistical variability for you to be able to be more likely to find patterns and associations. So it’s really a unique window of opportunity for us to potentially discover something new about breast cancer and its causes. But I think that some of the exposures that we’re focusing on are really quite unique to the Asian American diaspora.
And in fact, the challenge we’re having is how do we come up with a way to ask a certain question about a life experience that really is applicable across the diverse Asian American population. But I think the approach we need to be taking is recognizing the unique life experiences in our diverse communities and to design studies that tap into and capture those unique experiences.
Chris Riback: So what’s next? Is it literally having those conversations, starting that research and gathering the additional information?
Dr. Scarlett Gomez: Absolutely. Yes. We are starting recruitment. We have a survey that’s been finalized. We’re in the process of engaging, we have a vast network of community organizations and collaborators, and we’re really interested in hearing from women in the communities about what they think about breast cancer. We also, through some of our experiences with, we have a whole other portfolio on lung cancer among Asian American women who’ve never smoked and have learned that through the community engagement process, just getting the word out there has really allowed us to increase awareness about the issue among this community. So we’re hoping that this will provide an opportunity to do that as well.
Breast cancer remains really a stigma in our communities, and it’s not something that the community members talk about and because of that, so they’re not often aware of their risk of breast cancer. And that plays into some of our groups actually being diagnosed at later stages of disease because they are not up to date with regular screenings, do not follow up on concerning symptoms. So we hope to at least get the word out and to increase awareness about breast cancer among Asian American communities.
Chris Riback: Yes. I have heard about that problem with other groups and in other countries, not just in the U.S. but in different areas of the U.S. and in other countries. And what a wonderful initial benefit that you’re generating just by taking on the work, if you are almost as an externality, creating some initial awareness and getting people because, yes, the delayed diagnosis that can occur for a range of reasons, lack of access, cultural reasons, there are all sorts of reasons. Just to close out, I know you mentioned very briefly, but your BCRF grant is currently supported by The Estée Lauder Companies’ Travel Retail Award. What role would you characterize that BCRF has played in your research?
Dr. Scarlett Gomez: Yes. I think just to expand a bit about the comment I made earlier about this funding just being so unusual because I think this study that we’ve designed is not really something that could traditionally be funded through a grant, that one might write to, for example, the National Institutes of Health, for it to be funded. So I think just in itself, the fact that BCRF is willing to fund this, we think important work that I’ve been wanting to do for a long time and that many in our communities have been wanting to do for a long time is the major contribution.
I also had the opportunity back in October this past year at the BCRF Symposium and Luncheon to sit down and talk with some of the members from The Estée Lauder Companies’ [Travel Retail channel], which is supporting funding this research in addition to other [BCRF research projects], and hearing from them that they raised funds among their employees within [Travel Retail] and [elected to support] research on Asian American populations. So that actually was very meaningful and meant a lot to me. So, I feel especially grateful, but also responsible for the stewardship of these funds and making sure that we generate findings and data that are meaningful and impactful.
Chris Riback: I was going to say, I’m sure grateful, but also motivated. There’s another level of motivation. Dr. Gomez, thank you. Thank you for your time and thank you for the work that you do.
Dr. Scarlett Gomez: Thank you, Chris.
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