NEW YORK — For 49 years, Rose Hsu lived a Chinese-American dream.
The daughter of immigrants, she coasted through childhood in San Francisco's Chinatown, excelled in school, married a doctor and moved to the suburbs. She cherished her children, her home and everything that marked her as an American woman.
Then, in 1994, Hsu got breast cancer and discovered a medical truth doctors already knew: Although Asian nations have the world's lowest incidence of breast cancer, Asian women in the United States have the same risk as white women. An Asian woman's chance of getting breast cancer increases by more than 80% within a decade of arriving in this country.
The biological factors are abundantly clear, said Regina Zeigler, a National Cancer Institute physician who led a 1993 study on Asians and breast cancer.
"A woman coming to the U.S. from Asia probably gives up a naturally healthy diet for American processed foods," Zeigler said. She may exercise less and undergo stress in navigating a new culture. And a language barrier may prevent her from seeking medical help or understanding public service announcements.
More elusive, though, are a host of cultural factors--modesty, day-to-day philosophy--that narrow Asian women's odds of beating the disease.
Health officials are learning that the best way to battle those factors is to step out of the doctor's office and into the community.
The American-Italian Cancer Foundation, based in Manhattan's affluent Upper East Side, does most of its work in the city's poorer minority neighborhoods. Staff members drive a mobile mammography van to churches, community centers and health fairs, where they dole out information and perform free mammograms.
"We seek out underserved, uninsured women and those in culturally cloistered neighborhoods," said Gilda Zane, the group's executive director. "Immigrant women have their own language, their own culture, and they don't go out. So we have to try to get in."
Mei Tsing recently visited the Chinatown Health Clinic in Manhattan for her second mammogram in four years. She received her first after a Chinese doctor ran a workshop at her church in Flushing, Queens, in 1992.
Experts would say the 63-year-old woman should have first had the test 20 years ago and should receive it every year or two. But before Tsing trades her oversized Columbia University sweatshirt for a paper robe, she discounts the idea of visiting any doctor that often.
"I have other things that worry me more," said Tsing, whose mammogram turned up no problems.
That's a common, and dangerous, philosophy among immigrant women, Zane said.
"They worry about making a life for their family," she said, "not about a lump that doesn't hurt."
But finding such a lump is critical. Breast cancer is the most common type of cancer among adult women, but its sufferers boast strong survival rates--more than 70% live at least five years after diagnosis. The most likely survivors are the women who catch the disease before it can spread.
Most breast tumors are found by women examining themselves. But Asian women, typically modest, are loath to do that.
Hsu had made a few awkward attempts at examining her breasts.
"I thought if I had any problem, it would be really easy to see or to feel," she explained. She felt no lumps and wasn't comfortable with the process, so she didn't persist.
"There are very strong taboos about touching themselves," said Helen Jones of the American Cancer Society in San Francisco, which serves a large Asian population. "You must teach the same lessons, but you have to go about it in a culturally sensitive way."
To that end, the group produces instructional videos in Cantonese, Mandarin, Tagalog, Vietnamese and English, using Asian models. Many cancer organizations have hired Asian social workers and counselors. The San Francisco Department of Health is fully bilingual and publishes literature in several dialects.
Cultural sensitivity and medical conventions may present a delicate balance.
"We've had women who only want to see an herbalist," Jones said. "For a woman with a lump in her breast, I can't say that's enough."
After several years of gentle pestering by her family physician, Hsu had her first mammogram in March 1994. The test turned up a cancerous tumor, tiny enough to remove through a lumpectomy. The surgery, in which only the lump and lymph nodes were removed, was followed by several weeks of radiation.
"I was lucky, really," Hsu reflects.
But then came the nightmares. Visions of tumorous breasts filled her dreams. A new fear of dying, of leaving her husband and children, filled her waking hours.
At every physical checkup, her doctor proclaimed her good health. "And he did ask how I felt, emotionally," Hsu said.
The first time, she smiled and said she was fine. But the next time, she asked for help. Her husband had been supportive, even "sweet. But he kept saying, 'You're fine, there's nothing to worry about,' and I didn't believe that."