Factors Affecting Quality of Life for Korean American Cancer Survivors: An Integrative Review

The size of the Asian American population living in the United States is projected to increase by 132% and will comprise 9% of the total U.S. population by 2050 (U.S. Census Bureau, 2011). Compared to Caucasians, African Americans, and Hispanics, Asian Americans have distinctive profiles for leading causes of death. Cancer is the leading cause of death for Asian Americans (Centers for Disease Control and Prevention, 2013). Specific information on Asian American subgroups indicates that Korean Americans have the highest cancer mortality rates (Kwong, Chen, Snipes, Bal, & Wright, 2005) and the lowest breast and colorectal cancer screening rates (Lee, Ju, Vang, & Lundquist, 2010; Lee, Lundquist, Ju, Luo, & Townsend, 2011; Maxwell, Crespi, Antonio, & Lu, 2010). Korean American men (55 per 100,000) and women (28 per 100,000) have the highest incidence of stomach cancer compared to other Asian subgroups, which is five times higher than rates for non-Hispanic Caucasian men and seven times higher than rates for non-Hispanic Caucasian women (McCracken et al., 2007). Korean American women have the highest incidence and mortality rates for liver cancer compared to other Asian American subgroups, and Korean American men have the second highest incidence and mortality rates for liver and colorectal cancer (McCracken et al., 2007). Given the high incidence of cancer among Korean Americans and the dramatic increase in the percentage of Korean Americans (33%) living in the United States since 2000 (U.S. Census Bureau, 2012), oncology professionals likely will be caring for more Korean American cancer survivors and will need more accurate and culturally and ethnically relevant information about their cancer experience, quality of life (QOL), and factors that affect it.

One of the persistent problems in understanding the experience of Korean Americans with cancer is that studies often focus on Asian Americans as one large homogeneous group, a practice that obscures the heterogeneity that exists within the Asian American population (Hastings et al., 2015). Past epidemiologic studies indicate that lifestyle factors, genetics, nativity (foreign-born versus United States-born), socioeconomic factors, and environmental factors may influence the development of cancer and survival among immigrants. However, these findings vary by specific ethnicity designations within the broader racial categories (Gomez et al., 2010, 2013; Hastings et al., 2015; Kwong et al., 2005). Using aggregated data to represent all subgroups of Asian Americans hinders understanding of the diversity that exists across and within these subgroups (Holland & Palaniappan, 2012; Islam et al., 2010). In addition, aggregated data obscure the identification of risk factors and causes of mortality within each group, and also decrease the ability to tailor interventions to the unique needs of specific subgroups of Asian Americans (Hastings et al., 2015).

The current study uses an integrative review of the literature to address the limitations of aggregated data from multiple Asian American subgroups and increase understanding of Korean Americans’ cancer experience. The integrative review focused specifically on Korean American cancer survivors and examined their QOL and factors that affected it. This information is essential for fostering a better understanding of the cancer experience in this group and planning culturally and ethnically appropriate interventions to support them. In this review, the term cancer survivor refers to a person who has been diagnosed with cancer, including anyone who is currently getting treatments for cancer, as well as those who have been treated for cancer and are currently cancer-free.

Characteristics of Korean American Immigrants

The majority of Koreans came to the United States after Congress passed the Immigration and Naturalization Act of 1965 that enabled people from other countries to seek a better life, pursue their education, and join family members living in the United States (Zong & Batalova, 2014). The top three states where most Korean American immigrants live are California (30%), New York (9%), and New Jersey (6%) (U.S. Census Bureau, 2012). About 40% of Korean immigrants live in metropolitan areas, such as Los Angeles, New York, and Washington D.C. (U.S. Census Bureau, 2012). General demographic characteristics of Korean American immigrants in the United States indicate that more than half are foreign-born (born in South Korea) (U.S. Department of Homeland Security, 2011), 52% have a bachelor’s degree or higher (Zong & Batalova, 2014), and, among Asian American subgroups, they have the highest rate of self-employment (Pew Research Center, 2012). In a comparison of the six largest Asian American subgroups (Pew Research Center, 2012), Korean Americans had the lowest median household income ($50,000) despite having high educational attainment.

Korean American Cancer Survivors’ Cultural Values and Quality of Life

Research indicates that the QOL of Korean American patients with cancer is strongly influenced by their cultural norms (Kagawa-Singer, Dadia, Yu, & Surbone, 2010), which are based on Confucianism. In Confucianism, gender and familial roles are clearly delineated. Traditionally, men are the breadwinners and decision makers for the family (Park & Bernstein, 2008). Women are obligated to cook for the family, raise children, maintain the household, and help financially. These cultural norms shape family members’ expectations that wives and mothers who are diagnosed with cancer will continue their usual cultural and gender roles as caregivers and in managing the household. This conflict between expectations and the experience of living with cancer and its treatment creates enormous strains that negatively affect the emotional well-being of female cancer survivors (Tam Ashing, Padilla, Tejero, & Kagawa-Singer, 2003).

Although the literature on the QOL of Korean American cancer survivors is limited, prior research indicates that Korean American cancer survivors have lower levels of acculturation and lower QOL when compared to other Asian cancer survivors (Kim, Ashing-Giwa, Kagawa Singer, & Tejero, 2006). Korean American cancer survivors also report lower psychological QOL than their native Korean (residing in South Korea) counterparts, but higher physical QOL (Lim & Zebrack, 2008). Korean American cancer survivors report difficulty adjusting to cancer because of language barriers they face, which hinder their understanding of health information and ability to communicate with health professionals (Choi, Jun, & Anderson, 2012; Tam Ashing et al.,2003).

Because of the small number of studies in this area and acknowledged limitations of the literature, little is known about the QOL of Korean American cancer survivors. More information is needed on their QOL and associated factors to better understand and plan culturally and ethnically appropriate interventions to support them. This integrative review was conducted to assess the current state of the literature and to gain a better understanding of QOL issues among Korean American cancer survivors.

Literature Search

This integrative review was conducted with focused searches using PubMed, CINAHL®, Google Scholar, and EBSCO databases and was limited to studies published from January 2000 to January 2014. Searches were conducted using the following key words: Korean American or Asian American cancer patients or survivors’ experiences or quality of life (physical, mental, or psychological). The term quality of life had to be combined with either Korean American or Asian American, which were used as exploded Medical Subject Headings (MeSH) terms. For example, using the search Korean American cancer survivors’ quality of life, the MeSH terms of Korean American, cancer survivors, and quality of life were used in the PubMed database. English- and Korean-language publications were retrieved. Studies were included if they were primary quantitative, qualitative, or mixed-method studies that described the experience of Korean American cancer survivors and factors that influenced their QOL. Studies that were based on samples that focused broadly on Asian Americans’ QOL, but that reported the results for Korean Americans as a specific subgroup, were included in the review. Quotes from a qualitative study among Asian American cancer survivors also were included in this review if the quote was directly attributable to a Korean American cancer survivor.

Data Evaluation

Prior to data analysis, potential studies were reviewed by four researchers and any discrepancies were resolved by evaluating the overall quality of each study. Each study was rated on a two-point scale (high or low) based on the relevance of findings to the purpose of the review (Whittemore & Knafl, 2005). Also, studies were evaluated for adequate conceptual definitions of variables, appropriate use of research design and method, and appropriate data analyses.

Data from all studies included in the integrative review were extracted. The most commonly measured variables in the quantitative studies and the most commonly discussed issues in the qualitative studies that affected QOL of Korean American cancer survivors reflected three main themes: social support (types, amount, size, and quality), communication (family communication and patient–physician communication), and acculturation (cultural and language barriers, lack of culturally relevant resources, living as an immigrant, and cultural norms).

[[{"type":"media","view_mode":"media_original","fid":"23396","attributes":{"alt":"","class":"media-image","height":"526","typeof":"foaf:Image","width":"369"}}]]

Findings

A total of 13 studies that included Korean American cancer survivors were retrieved from the search: 7 quantitative studies, 5 qualitative studies, and 1 mixed-method study (see Figure 1). Table 1 provides details about the 13 studies. All studies were obtained in English, except one qualitative study that was written in Korean (Choi et al., 2012). Two studies consisted of Korean Americans only, nine studies included Korean Americans with other Asian American ethnic groups, and two studies compared native Koreans (i.e., Korean nationality) to Korean Americans. The number of Korean Americans in the studies ranged from fewer than 10 (Lee et al., 2013) to as many as 71 (Lim & Ashing-Giwa, 2013; Lim & Paek, 2013).

Demographic Characteristics

The mean age of the cancer survivors was 56 years. A majority of participants in the studies reviewed attained more than a high school degree (i.e., some college education) and had an average income level of less than $25,000. Cancer survivors’ average length of stay in the United States was 22 years, and 98% of them were born in Korea. Of the 13 studies reviewed, all were conducted with female cancer survivors. Most studies were conducted with women with breast cancer (n = 10), and a few were conducted with women with gynecologic cancer (n = 3). Korean American breast and gynecologic cancer survivors generally had lower income but higher education than their native Korean counterparts (Lim & Yi, 2009; Lim & Zebrack, 2008). Korean American breast cancer survivors had the lowest income compared to other Asian American breast cancer ethnic groups (Japanese, Chinese, Filipino, and other small Asian groups) and also the lowest level of QOL (Kim et al., 2006).

Several socioeconomic indicators predicted or were related to QOL. Income was inversely associated with psychological distress and positively associated with QOL (Lim & Yi, 2009). Higher education was associated with positive physical and mental QOL (Lim & Ashing-Giwa, 2013). In regard to acculturation factors, language barriers were identified as a primary indicator of Korean American cancer survivors’ level of acculturation. Higher levels of acculturation (reduced language barriers) were positively related to their level of QOL. High language barriers were related to lower social network involvement (Kim et al., 2006; Lim, Yi, & Zebrack, 2008). Longer length of stay in the United States was positively associated with larger social network size, greater social involvement, and fewer language barriers (Lim et al., 2008).

Social Support Perceptions of Korean American Patients and Caregivers

Studies included in the integrative review documented the importance of social support for Korean American cancer survivors’ QOL. Greater perceived social support was one of the factors that positively influenced greater levels of well-being in a study of Korean American gynecologic and breast cancer survivors (p < 0.01) (Lim & Zebrack, 2008). Social support was also negatively associated with psychological distress (p < 0.01), and the positive impact of spirituality for better overall QOL was mediated via perceived social support (Lim & Yi, 2009). Lim (2014) also found that breast cancer survivors who used more social support from extended family, friends, and neighbors, or sought more spiritual support, had better mental-related QOL. In addition, those with positive social network structures (i.e., larger network size, more diverse networks, and greater network involvement) had better emotional support and QOL (Lim et al., 2008). These studies all suggest that social support is a key factor related to Korean American cancer survivors’ QOL and that social network size and network involvement have a positive influence on emotional support. However, Korean American cancer survivors had significantly smaller networks and less network involvement compared to native Korean cancer survivors (Lim & Zebrack, 2008).

Five qualitative studies found that family was perceived as a major source of support and a major source of stress for Korean American cancer survivors. Perceived stress can be attributed to survivors’ adherence to ethnic values that emphasize the importance of fulfilling family role expectations even after receiving a cancer diagnosis. Perceiving family as a source of stress also was associated with survivors’ belief that their family members did not know or understand what they were really going through (Ashing-Giwa et al., 2004; Choi et al., 2012; Lee et al., 2013; Lim, Gonzalez, Wang-Letzkus, Baik, & Ashing-Giwa, 2013; Tam Ashing et al., 2003). For example, a breast cancer survivor said, “My family expects me to work and function the same as before the surgery. It saddens me” (Tam Ashing et al., 2003, p. 45). Older adult Korean American cancer survivors reported that seeking support from younger adult family members was difficult because they did not want to become a burden by relying on them too much. Older adult survivors felt that cancer was their battle to wage alone (Ashing-Giwa et al., 2004; Choi et al., 2012; Lee et al., 2013; Tam Ashing et al., 2003). To illustrate, a Korean American oncologist said, “Older generations feel that they are a burden to their family, so that’s another different issue that some of my patients do go through” (compared to American patients) (Lee et al., 2013, p. 5).

Obtaining support from the community was also difficult for Korean Americans. Studies indicate that cancer survivors wanted support groups to share feelings and experiences (Ashing-Giwa et al., 2004; Choi et al., 2012; Lee et al., 2013; Tam Ashing et al., 2003) but were not able to locate support groups that were language-appropriate (i.e., conducted in Korean). In addition, because many community members were immigrants who had demanding work commitments for surviving through immigrant life, cancer survivors did not perceive that they had much support from their own Korean American community. Korean American cancer survivors also perceived a lack of support from the Western community (Lim, Baik, & Ashing-Giwa., 2012). Language barriers were a primary reason that limited their ability to relate and share their feelings freely with people from the Western community. One cancer survivor said, “Americans don’t seem to share their emotions with immigrants like us. They don’t try to talk to us first” (Lim et al., 2012, p. 393). As a consequence, cancer survivors were unable to receive emotional support from either the Korean or Western communities (Choi et al., 2012; Lee et al., 2013; Lim et al., 2012, 2013). Additional quotes are provided in Figure 2.

Communication and Cancer

Several quantitative studies examined the relationship between Korean Americans’ communication behaviors and their physical and mental QOL. Lim (2014) found that cancer survivors who communicated effectively within the family improved their physical (p < 0.001) and mental QOL (p < 0.01). Similarly, among 71 Korean American breast cancer survivors, family communication was directly associated with mental and physical QOL (p < 0.05) (Lim & Paek, 2013). Other studies focusing specifically on family relationships found that greater family support was related to more family communication (p = 0.002) (Lim & Ashing-Giwa, 2013).

Communication within a family was sometimes a barrier for Korean American cancer survivors. Choi et al. (2012) found that, although their main emotional support came from family members, cancer survivors had difficulty communicating with their second-generation adult children because of language barriers. Adult children were more fluent in English, and first-generation immigrant cancer survivors were more fluent in Korean. First-generation Korean American cancer survivors identified this language barrier as an obstacle to receiving adequate emotional support from their family.

Korean American cancer survivors also perceive that cancer-associated stigma has limited their ability to effectively communicate with their family members and others. Some Korean American cancer survivors felt ashamed of having cancer, which made them reluctant to talk about their feelings with others who were healthy (Choi et al., 2012; Lee et al., 2013). Because of the stigma, they also limited their interactions with others but then felt lonely and distressed. By hiding their cancer, Korean American cancer survivors were able to avoid hearing negative comments or questions such as, “How much longer (can you live)?” (Lee et al., 2013). They indicated that negative comments from others were difficult to hear and had a negative effect on their QOL (Choi et al., 2012; Lee et al., 2013). Feelings of shame for having cancer and the need to protect themselves from others’ comments were reported mainly by female cancer survivors whose observance of cultural norms prevented them from sharing their experiences (Im, Lee, & Park, 2002).

Studies examining communication and the relationships between Korean American patients with cancer and their physicians (Lim et al., 2012) found that physicians’ assistance in managing patients’ stress had positive effects on QOL. In qualitative studies, Korean American cancer survivors reported that their doctors’ attitudes and communication were important to them during their cancer treatment and follow-up care (Choi et al., 2012; Lim et al., 2012). However, some Korean breast cancer survivors said that they worried that asking too many questions could result in a negative relationship with their physicians. This was not the belief of other Asian subgroups, who felt that patients should ask their physician questions (Tam Ashing et al., 2003).

In general, first-generation cancer survivors said they preferred a Korean-speaking oncologist because they would be able to understand information about their course of disease more easily (Choi et al., 2012). However, finding a Korean-speaking oncologist within their Korean American community was difficult for survivors. In addition, Korean American cancer survivors said they were limited to hospitals or oncologists that were covered by their insurance. This hindered their ability to find a Korean American oncologist who also spoke Korean and with whom they could have effective communication.

Acculturation

Degree of acculturation to their host culture is highly related to health-related QOL (Janz et al., 2009). In studies of Korean American cancer survivors, greater acculturation influenced their multidimensional QOL through better social support (Lim et al., 2008), and greater acculturation was directly related to greater social support (Lim & Ashing-Giwa, 2013). In both studies, the degree of acculturation was assessed using measures of cultural identity and knowledge, language use, and food and diet patterns, as well as additional acculturation factors, such as birthplace, primary language and language barriers, and length of stay in the United States. Studies of acculturation indicated that Korean American cancer survivors were much less acculturated compared to Chinese cancer survivors, even with comparable lengths of stay in the United States (Lim & Ashing-Giwa, 2013). In addition, those who completed surveys in English were more acculturated than those who completed surveys in their own native language. Among Asian groups (Chinese, Filipino, Japanese, and others), Korean Americans had the highest rate of completing surveys in their own language, suggesting lower levels of acculturation (Kim et al., 2006; Lim et al., 2008).

Acculturative stress is a common response to the process of acculturation that is reflected in lower mental health status (confusion, anxiety, and depression), higher psychosomatic symptom level, and identity confusion (Berry, Kim, Minde, & Mok, 1987). Factors associated with acculturative stress can lead to lower levels of QOL among immigrant cancer survivors versus nonimmigrant cancer survivors (Butow et al., 2013; Lucket et al., 2011). Immigrants who are diagnosed with cancer reported compounded stress from a variety of sources, in addition to the stress of being an immigrant. Korean Americans who receive a cancer diagnosis reported more stress from: (a) lack of knowledge or education related to understanding of the U.S. health system (e.g., health insurance) and finding resources; (b) language barriers related to understanding health-related materials after surgery, chemotherapy instructions, or side effects from clinicians; (c) lack of support and availability of Korean cancer support groups; and (d) having to work while being treated for cancer because of lack of insurance and need to support their immigrant family.

Findings from qualitative studies indicate that cancer survivors had limited understanding of the U.S. healthcare system related to its high cost and fragmented care system, and had a lack of trust in the system (Choi et al., 2012; Tam Ashing et al., 2003). Also, breast cancer survivors did not have knowledge or education specific to cancer genetic testing or about the need for cancer screening in situations of a family history of breast cancer (Choi et al., 2012; Tam Ashing et al., 2003). Finally, because of their limited English and language barriers, Korean American cancer survivors played a less active role in their treatment plan and were less likely ask questions or express concerns (Tam Ashing et al., 2003).

Discussion

This integrative review identified 13 studies focused on factors affecting the QOL of Korean American patients with cancer. The most common factors or topics that were studied were social support, communication, and acculturation, which all demonstrated significant relationships to QOL. More specifically, greater family support, better family communication, and greater level of acculturation were associated with greater QOL among Korean Americans. The central findings of this review are that Korean American patients with cancer: (a) received inadequate social support from their own ethnic community and the Western community, (b) had difficulty communicating with their adult children, (c) experienced stigma from having cancer, (d) were not able to receive health information in their own language, and (e) experienced acculturative stress, which hindered effective communication with others and, ultimately, affected their QOL. These findings are consistent with a literature review of studies of Asian American breast cancer survivors living in the United States (Wen, Fang, & Ma, 2014). In that literature review, quantitative studies indicated that cultural health beliefs, immigration stress, acculturation level, English proficiency, social support, and spirituality were associated with Asian American breast cancer survivors’ QOL. The qualitative studies indicated that cancer survivors reported a lack of physical and emotional support, a lack of knowledge, and language barriers during cancer survivorship.

An important finding from the current review of quantitative and qualitative studies was that Korean American cancers survivors often are uncomfortable or uncertain about interacting with their oncologists. Korean American cancer survivors were hesitant to ask questions and worried that asking too many questions would have a negative effect on their doctor–patient relationship. Female Korean American cancer survivors often deferred to their physicians when considering treatments, were less active in the decision-making process (Tam Ashing et al., 2003), and wanted to follow their doctors’ recommendations to promote a good relationship (Lim et al., 2012). Korean Americans’ deference to their physicians may be associated with the fact that most of them were older adult, first-generation immigrants who were strongly influenced by their Koran cultural beliefs and less likely to be acculturated.

The integrative review also indicated that because families are the main source of social support for Korean American cancer survivors, family caregivers of cancer survivors should be included in additional studies. However, caregiving is part of cultural obligation (rather than being voluntary) in Korean culture (Han, Choi, Kim, Lee, & Kim, 2008). Because of this, a full appreciation of the cultural meaning of caregiving will be crucial for assessing the patient–caregiver relationship. Past studies indicate that Korean American caregivers have greater levels of depression, burden, and anxiety than Caucasian caregivers (Lee & Farran, 2004; Youn, Knight, Jeong, & Benton, 1999), suggesting that they also may have needs for specific types of information and support as caregivers.

Limitations

The current review is constrained by a number of limitations in the existing literature on the QOL of Korean American patients with cancer and their caregivers. Only two studies (Choi et al., 2012; Lim et al., 2008) focused exclusively on Korean American cancer survivors. Although the remaining studies included Korean Americans as one subgroup of Asian Americans, analyzing the experiences of only Korean American cancer survivors was challenging. Studies in the integrative review were focused on breast and gynecologic cancer survivors (Ashing Giwa et al., 2004; Choi et al., 2012; Kim et al., 2006; Lee et al., 2013; Lim, 2014; Lim & Ashing-Giwa, 2013; Lim & Paek, 2013; Lim et al., 2012, 2013; Tam Ashing et al., 2003), which limited the researchers’ understanding of the relationship between support, communication, and acculturation among survivors coping with other types of cancer. Also, the findings may be relevant primarily to female Korean American cancer survivors who made up the sample for most of the studies reviewed. The majority of the studies were conducted by the same team of researchers using a few large surveys, which may limit the generalizability of the findings. Most of studies had small sample sizes. Finally, the research designs in prior studies were primarily secondary analyses, cross-sectional, or qualitative, limiting the researchers’ understanding of the experience of Korean American cancer survivors over time.

Implications for Research

Given the paucity of research on Korean American cancer survivors, a need exists for more research, including descriptive, exploratory, and longitudinal studies that focus only on Korean Americans. Studies with larger samples of Korean American cancer survivors will further clarify the relationships between social support, communication, acculturation, and QOL. Also, additional studies will need to assess Korean American survivors of different types of cancer. Because of the high incidence of stomach and liver cancer among Korean Americans, the fact that none of the studies included survivors with these types of cancer is surprising. In addition, because Korean Americans have the lowest use of cancer screening compared to other Asian subgroups (Lee et al., 2010, 2011; Maxwell et al., 2010), studies focusing on increasing cancer screening using culturally tailored interventions are needed.

Implications for Practice

Understanding and acknowledging the cultural background of Korean American cancer survivors is essential to improving their QOL. Based on the concept of Confucianism and filial piety, Korean American cancer survivors may not seek professional help to build social support, improve communication skills, or report feelings of depression or stress. Clinicians will need to pay closer attention to the quality of family communication because families prefer to resolve conflicts internally or may try to avoid even talking about conflicts. Therefore, providing a safe environment for patients with cancer and their family caregivers to talk about health-related issues is important. Also important is for healthcare professionals to understand that Korean Americans may prefer to make medical decisions as a family rather than leave these decisions to the patient only.

The findings indicated that most first-generation Korean American cancer survivors will trust their clinicians and take their recommendations during decision making; therefore, clinicians play a critical role in the decision-making process. Providing health information (e.g., side effects of treatments, healthy behaviors, postsurgical complications, reconstructive surgery options) in an easy-to-understand manner will help reduce survivors’ stress during the cancer experience and promote better QOL. Also, having an interpreter present during consultations may help cancer survivors to ask questions more freely without having to rely on their own interpreter (e.g., friends, family members) to enhance making an autonomous decision.

The American Cancer Society ([ACS], 2015) has educational materials for various Asian or Pacific Islander languages, including Korean. For Koreans, educational materials are related to cancer prevention and early detection, side effects and treatment, general knowledge of different types of cancer, healthy behaviors, caregiving, and the patient–doctor relationship. Korean American cancer survivors respond positively when clinicians provide informational brochures. Providing culturally appropriate educational materials could prove to be useful in informing patients and their caregivers.

Most Korean Americans rely on their own ethnic community centers and churches for social support to extend their social networks and to access health services. Given this, clinicians or public health nurses may need to work with ethnic-affiliated community-based organizations to provide culturally effective nursing interventions. Collaborating with Korean American community centers is critical because they have staff members who can speak English, Korean, or both languages to help patients and caregivers. Because community centers may have already established good rapport and relationships with cancer survivors, providing education or support groups through community centers can provide a safe environment for cancer survivors to talk about their emotions or ask for help. For second-generation cancer survivors who prefer to join non-Korean American organizations, an organization like the Cancer Support Community (www.cancersupportcommunity.org) can be a useful resource where they can receive psychosocial care at no cost.

Finally, acknowledging the importance of providing culturally appropriate programs at nonprofit organizations is imperative. Western-oriented therapy or support groups focus on open communication and discussions about conflicts, and emphasize individuals compared to families (Leong & Lau, 2001). These are all features of therapeutic approaches that are unfamiliar and more difficult for people from Asian cultures. Modifications of this form of therapy (e.g., a greater emphasis on spirituality) are needed to enhance the effectiveness of therapy or a support group for Korean Americans or other ethnic groups who follow Confucianism values.

Conclusion

In summary, cancer is recognized as the leading cause of death for Korean Americans in the United States, a population that will increase in size in the coming decades. This review of the literature identified social support, communication, and acculturation as key factors related to QOL in Korean American cancer survivors. These findings have implications for additional research on Korean American cancer survivors, as well as for healthcare professionals who may provide care to this group. Ongoing efforts to infuse research and practice with culturally relevant and sensitive interventions and therapeutic approaches hold promise for ensuring that Korean American patients and their families receive high-quality care that improves their QOL.

References

American Cancer Society. (2015). Cancer information in Asian and Pacific languages. Retrieved from http://www.cancer.org/asianlanguagematerials/index

Ashing-Giwa, K.T., Padilla, G., Tejero, J., Kraemer, J., Wright, K., Coscarelli, A., . . . Hills, D. (2004). Understanding the breast cancer experience of women: A qualitative study of African American, Asian American, Latina and Caucasian cancer survivors. Psycho-Oncology, 13, 408–428. doi:10.1002/pon.750

Berry, J.W., Kim, U., Minde, T., & Mok, D. (1987). Comparative studies of acculturative stress. International Migration Review, 21, 491–511. doi:10.2307/2546607

Butow, P.N., Aldridge, L., Bell, M.L., Sze, M., Eisenbruch, M., Jefford, M., . . . Goldstein, D. (2013). Inferior health-related quality of life and psychological well-being in immigrant cancer survivors: A population-based study. European Journal of Cancer, 49, 1948–1956. doi:10.1016/j.ejca.2013.01.011

Centers for Disease Control and Prevention. (2013). Leading causes of death and numbers of deaths, by sex, race, and Hispanic origin: United States, 1980 and 2013. Retrieved from http://www.cdc.gov/nchs/data/hus/2014/020.pdf

Choi, K.S., Jun, M., & Anderson, G. (2012). Experiences of Korean-American women with high risk hereditary breast cancer. Asian Oncology Nursing, 12, 175–185. doi:10.5388/aon.2012.12.2.175

Gomez, S.L., Noone, A.M., Lichtensztajn, D.Y., Scoppa, S., Gibson, J.T., Liu, L., . . . Miller, B.A. (2013). Cancer incidence trends among Asian American populations in the United States, 1990–2008. Journal of the National Cancer Institute, 105, 1096–1110. doi:10.1093/jnci/djt157

Gomez, S.L., Quach, T., Horn-Ross, P.L., Pham, J.T., Cockburn, M., Chang, E.T., . . . Clarke, C.A. (2010). Hidden breast cancer disparities in Asian women: Disaggregating incidence rates by ethnicity and migrant status. American Journal of Public Health, 100(Suppl. 1), 125–131. doi:10.2105/AJPH.2009.163931

Han, H.R., Choi, Y.J., Kim, M.T., Lee, J.E., & Kim, K.B. (2008). Experiences and challenges of informal caregiving for Korean immigrants. Journal of Advanced Nursing, 63, 517–526. doi:10.1111/j.1365-2648.2008.04746.x

Hastings, K.G., Jose, P.O., Kapphahn, K.I., Frank, A.T., Goldstein, B.A., Thompson, C.A., . . . Palaniappan, L.P. (2015). Leading causes of death among Asian American subgroups (2003–2011). PLOS One, 10, e0124341. doi:10.1371/journal.pone.0124341

Holland, A.T., & Palaniappan, L.P. (2012). Problems with the collection and interpretation of Asian-American health data: Omission, aggregation, and extrapolation. Annals of Epidemiology, 22, 397–405. doi:10.1016/j.annepidem.2012.04.001

Im, E.O., Lee, E.O., & Park, Y.S. (2002). Korean women’s breast cancer experience. Western Journal of Nursing Research, 24, 751–771. doi:10.1177/019394502762476960

Islam, N.S., Khan, S., Kwon, S., Jang, D., Ro, M., & Trinh-Shevrin, C. (2010). Methodological issues in the collection, analysis, and reporting of granular data in Asian American populations: Historical challenges and potential solutions. Journal of Health Care for the Poor and Underserved, 21, 1354–1381.

Janz, N.K., Mujahid, M.S., Hawley, S.T., Griggs, J.J., Alderman, A., Hamilton, A.S., . . .Katz, S.J. (2009). Racial/ethnic differences in quality of life after diagnosis of breast cancer. Journal of Cancer Survivorship, 3, 212–222. doi:10.1007/s11764-009-0097-y

Kagawa-Singer, M., Dadia, A.V., Yu, M.C., & Surbone, A. (2010). Cancer, culture, and health disparities: Time to chart a new course? CA: A Cancer Journal for Clinicians, 60, 12–39. doi:10.3322/caac.20051

Kim, J., Ashing-Giwa, K.T., Kagawa Singer, M., & Tejero, J.S. (2006). Breast cancer among Asian Americans: Is acculturation related to health-related quality of life? Oncology Nursing Forum, 33, E90–E99. doi:10.1188/06.ONF.E90-E99

Kwong, S.L., Chen, M.S., Jr., Snipes, K.P., Bal, D.G., & Wright, W.E. (2005). Asian subgroups and cancer incidence and mortality rates in California. Cancer, 104(12 Suppl.), 2975–2981.

Lee, E.E., & Farran, C.J. (2004). Depression among Korean, Korean American, and Caucasian American family caregivers. Journal of Transcultural Nursing, 15, 18–25. doi:10.1177/1043659603260010

Lee, H.Y., Ju, E., Vang, P.D., & Lundquist, M. (2010). Breast and cervical cancer screening disparity among Asian American women: Does race/ethnicity matter [corrected]? Journal of Women’s Health, 19, 1877–1884. doi:10.1089/jwh.2009.1783

Lee, H.Y., Lundquist, M., Ju, E., Luo, X., & Townsend, A. (2011). Colorectal cancer screening disparities in Asian Americans and Pacific Islanders: Which groups are most vulnerable? Ethnicity and Health, 16, 501–518. doi:10.1080/13557858.2011.575219

Lee, S., Chen, L., Ma, G.X., Fang, C.Y., Oh, Y., & Scully, L. (2013). Challenges and needs of Chinese and Korean American breast cancer survivors: In-depth interviews. North American Journal of Medical Sciences, 6, 1–8.

Leong, F.T., & Lau, A.S. (2001). Barriers to providing effective mental health services to Asian Americans. Mental Health Services Research, 3, 201–214. doi:10.1023/A:1013177014788

Lim, J.W. (2014). Communication, coping, and quality of life of breast cancer survivors and family/friend dyads: A pilot study of Chinese-Americans and Korean-Americans. Psycho-Oncology, 23, 1243–1251. doi:10.1002/pon.3532

Lim, J.W., & Ashing-Giwa, K.T. (2013). Is family functioning and communication associated with health-related quality of life for Chinese- and Korean-American breast cancer survivors? Quality of Life Research, 22, 1319–1329. doi:10.1007/s11136-012-0247-y

Lim, J.W., Baik, O.M., & Ashing-Giwa, K.T. (2012). Cultural health beliefs and health behaviors in Asian American breast cancer survivors: A mixed-methods approach. Oncology Nursing Forum, 39, 388–397. doi:10.1188/12.ONF.388-397

Lim, J.W., Gonzalez, P., Wang-Letzkus, M.F., Baik, O., & Ashing-Giwa, K.T. (2013). Health behavior changes following breast cancer treatment: A qualitative comparison among Chinese American, Korean American, and Mexican American survivors. Journal of Health Care for the Poor and Underseved, 24, 599–618.

Lim, J.W., & Paek, M.S. (2013). The relationship between communication and health-related quality of life in survivorship care for Chinese-American and Korean-American breast cancer survivors. Supportive Care in Cancer, 21, 1157–1166.

Lim, J.W., & Yi, J. (2009). The effects of religiosity, spirituality, and social support on quality of life: A comparison between Korean American and Korean breast and gynecologic cancer survivors. Oncology Nursing Forum, 36, 699–708. doi:10.1188/09.ONF.699-708

Lim, J.W., Yi, J., & Zebrack, B. (2008). Acculturation, social support, and quality of life for Korean immigrant breast and gynecological cancer survivors. Ethnicity and Health, 13, 243–260.

Lim, J.W., & Zebrack, B. (2008). Different pathways in social support and quality of life between Korean American and Korean breast and gynecological cancer survivors. Quality of Life Research, 17, 679–689. doi:10.1007/s11136-008-9343-4

Luckett, T., Goldstein, D., Butow, P.N., Gebski, V., Aldridge, L.J., McGrane, J., . . . King, M.T. (2011). Psychological morbidity and quality of life of ethnic minority patients with cancer: A systematic review and meta-analysis. Lancet Oncology, 12, 1240–1248. doi:10.1016/S1470-2045(11)70212-1

Maxwell, A.E., Crespi, C.M., Antonio, C.M., & Lu, P. (2010). Explaining disparities in colorectal cancer screening among five Asian ethnic groups: A population-based study in California. BMC Cancer, 10, 214. doi:10.1186/1471-2407-10-214

McCracken, M., Olsen, M., Chen, M.S., Jr., Jemal, A., Thun, M., Cokkinides, V., . . . Ward, E. (2007). Cancer incidence, mortality, and associated risk factors among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese ethnicities. CA: A Cancer Journal for Clinicians, 57, 190–205. doi:10.3322/canjclin.57.4.190

Park, S.Y., & Bernstein, K.S. (2008). Depression and Korean American immigrants. Archives of Psychiatric Nursing, 22, 12–19.

Pew Research Center. (2012). The rise of Asian Americans. Retrieved from http://www.pewsocialtrends.org/2012/06/19/the-rise-of-asian-americans

Tam Ashing, K., Padilla, G., Tejero, J., & Kagawa-Singer, M. (2003). Understanding the breast cancer experience of Asian American women. Psycho-Oncology, 12, 38–58. doi:10.1002/pon.632

U.S. Census Bureau. (2011). Asian/Pacific American heritage month: May 2011. Retrieved from https://www.census.gov/newsroom/releases/archives/facts_for_features_sp…

U.S. Census Bureau. (2012). The Asian population: 2010. Retrieved from https://www.census.gov/prod/cen2010/briefs/c2010br-11.pdf

U.S. Department of Homeland Security. (2011). 2010 yearbook of immigration statistics. Retrieved from https://www.dhs.gov/xlibrary/assets/statistics/yearbook/2010/ois_yb_201…

Wen, K.Y., Fang, C.Y., & Ma, G.X. (2014). Breast cancer experience and survivorship among Asian Americans: A systematic review. Journal of Cancer Survivorship, 8, 94–107. doi:10.1007/s11764-013-0320-8

Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52, 546–553. doi:10.1111/j.1365-2648.2005.03621.x

Youn, G., Knight, B.G., Jeong, H.S., & Benton, D. (1999). Differences in familism values and caregiving outcomes among Korean, Korean American, and White American dementia caregivers. Psychology and Aging, 14, 355–364. doi:10.1037/0882-7974.14.3.355

Zong, J., & Batalova, J. (2014, December 3). Korean immigrants in the United States. Migration Information Source. Retrieved from http://www.migrationpolicy.org/article/korean-immigrants-united-states

About the Author(s)

Yoon is an assistant professor in the Marcella Niehoff School of Nursing at Loyola University in Chicago, IL; Chatters is a professor in the School of Social Work and School of Public Health, and Kao is an assistant professor, Saint-Arnault is an associate professor, and Northouse is professor emerita, all in the School of Nursing, all at the University of Michigan in Ann Arbor.No financial relationships to disclose. Yoon, Chatters, Kao, Saint-Arnault, and Northouse contributed to the conceptualization and design. Yoon completed the data collection and provided the statistical support. Yoon, Chatters, Kao, and Northouse contributed to the analysis. Yoon, Chatters, Kao, Saint-Arnault, and Northouse contributed to the manuscript preparation.Yoon can be reached at hyoon3@luc.edu, with copy to editor at ONFEditor@ons.org. Submitted July 2015. Accepted for publication December 12, 2015.