Risk of cancer-specific, cardiovascular, and all-cause mortality among Asian and Pacific Islander breast cancer survivors in the United States, 1991-2011

Reducing racial and ethnic disparities in cardiovascular outcomes among cancer survivors

PURPOSE OF REVIEW

Analyze current evidence on racial/ethnic disparities in cardiovascular outcomes among cancer survivors, identifying factors and proposing measures to address health inequities.

RECENT FINDINGS

Existing literature indicates that the Black population experiences worse cardiovascular outcomes following the diagnosis of both initial primary cancer and second primary cancer, with a notably higher prevalence of cardio-toxic events, particularly among breast cancer survivors. Contributing socioeconomic factors to these disparities include unfavorable social determinants of health, inadequate insurance coverage, and structural racism within the healthcare system. Additionally, proinflammatory epigenetic modification is hypothesized to be a contributing genetic variation factor. Addressing these disparities requires a multiperspective approach, encompassing efforts to address racial disparities and social determinants of health within the healthcare system, refine healthcare policies and access, and integrate historically stigmatized racial groups into clinical research. Racial and ethnic disparities persist in cardiovascular outcomes among cancer survivors, driven by multifactorial causes, predominantly associated with social determinants of health. Addressing these healthcare inequities is imperative, and timely efforts must be implemented to narrow the existing gap effectively.

Cardio-Oncology and Heart Failure: A Scientific Statement from the Heart Failure Society of America

Heart failure and cancer remain two of the leading causes of morbidity and mortality and the two disease entities are linked in a complex manner. Patients with cancer are at increased risk of cardiovascular complications related to the cancer therapies. The presence of cardiomyopathy or heart failure in a patient with new cancer diagnosis portends a high risk for adverse oncology and cardiovascular outcomes. With the rapid growth of cancer therapies, many of which interfere with cardiovascular homeostasis, heart failure practitioners need to be familiar with prevention, risk stratification, diagnosis, and management strategies in cardio-oncology. This Heart Failure Society of America statement addresses the complexities of heart failure care among patients with active cancer diagnosis and cancer survivors. Risk stratification, monitoring, and management of cardiotoxicity are presented across Stages A through D heart failure, with focused discussion on heart failure preserved ejection fraction and special populations such as survivors of childhood and young adulthood cancers. We provide an overview of the shared risk factors between cancer and heart failure, highlighting heart failure as a form of cardiotoxicity associated with many different cancer therapeutics. Finally, we discuss disparities in the care of patients with cancer and cardiac disease and present a framework for a multidisciplinary team approach and critical collaboration between heart failure, oncology, palliative care, pharmacy, and nursing teams in the management of these complex patients.

Risk of contralateral breast cancer among Asian/Pacific Islander women in the United States

PURPOSE

While breast cancer studies often aggregate Asian/Pacific Islander (API) women, as a single group or exclude them, this population is heterogeneous in terms of genetic background, environmental exposures, and health-related behaviors, potentially resulting in different cancer outcomes. Our purpose was to evaluate risks of contralateral breast cancer (CBC) among subgroups of API women with breast cancer.

METHODS

We conducted a retrospective cohort study of women ages 18 + years diagnosed with stage I-III breast cancer between 2000 and 2016 in the Surveillance, Epidemiology and End Results registries. API subgroups included Chinese, Japanese, Filipina, Native Hawaiian, Korean, Vietnamese, Indian/Pakistani, and other API women. Asynchronous CBC was defined as breast cancer diagnosed in the opposite breast 12 + months after first primary unilateral breast cancer. Multivariable-adjusted subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) were estimated and stratified by API subgroups.

RESULTS

From a cohort of 44,362 API women with breast cancer, 25% were Filipina, 18% were Chinese, 14% were Japanese, and 8% were Indian/Pakistani. API women as an aggregate group had increased risk of CBC (SHR 1.15, 95% CI 1.08-1.22) compared to NHW women, among whom Chinese (SHR 1.23, 95% CI 1.08-1.40), Filipina (SHR 1.37, 95% CI 1.23-1.52), and Native Hawaiian (SHR 1.69, 95% CI 1.37-2.08) women had greater risks.

CONCLUSION

Aggregating or excluding API patients from breast cancer studies ignores their heterogeneous health outcomes. To advance cancer health equity among API women, future research should examine inequities within the API population to design interventions that can adequately address their unique differences.

Causes of death in women with breast cancer: a risks and rates study on a population-based cohort

Introduction

The increasing survival of patients with breast cancer has prompted the assessment of mortality due to all causes of death in these patients. We estimated the absolute risks of death from different causes, useful for health-care planning and clinical prediction, as well as cause-specific hazards, useful for hypothesis generation on etiology and risk factors.

Materials and methods

Using data from population-based cancer registries we performed a retrospective study on a cohort of women diagnosed with primary breast cancer. We carried out a competing-cause analysis computing cumulative incidence functions (CIFs) and cause-specific hazards (CSHs) in the whole cohort, separately by age, stage and registry area.

Results

The study cohort comprised 12,742 women followed up for six years. Breast cancer showed the highest CIF, 13.71%, and cardiovascular disease was the second leading cause of death with a CIF of 3.60%. The contribution of breast cancer deaths to the CIF for all causes varied widely by age class: 89.25% in women diagnosed at age <50 years, 72.94% in women diagnosed at age 50-69 and 48.25% in women diagnosed at age ≥70. Greater CIF variations were observed according to stage: the contribution of causes other than breast cancer to CIF for all causes was 73.4% in women with stage I disease, 42.9% in stage II-III and only 13.2% in stage IV. CSH computation revealed temporal variations: in women diagnosed at age ≥70 the CSH for breast cancer was equaled by that for cardiovascular disease and "other diseases" in the sixth year following diagnosis, and an early peak for breast cancer was identified in the first year following diagnosis. Among women aged 50-69 we identified an early peak for breast cancer followed by a further peak near the second year of follow-up. Comparison by geographic area highlighted conspicuous variations: the highest CIF for cardiovascular disease was more than 70% higher than the lowest, while for breast cancer the highest CIF doubled the lowest.

Conclusion

The integrated interpretation of absolute risks and hazards suggests the need for multidisciplinary surveillance and prevention using community-based, holistic and well-coordinated survivorship care models.

Survival of Filipino women with breast cancer in the United States

BACKGROUND

The survival of women with early-stage breast cancer varies by racial group. Filipino women with breast cancer are an understudied group and are often combined with other Asian groups. We compared clinical presentations and survival rates for Filipino and White women with breast cancer diagnosed in the United States.

METHODS

We conducted a retrospective cohort study of women with breast cancer diagnosed between 2004 and 2015 in the SEER18 registries database. We compared crude survival between Filipino and White women. We then calculated adjusted hazard ratios (HR) in a propensity-matched design using the Cox proportional hazards model.

RESULTS

There were 10,834 Filipino (2.5%) and 414,618 White women (97.5%) with Stage I-IV breast cancer in the SEER database. The mean age at diagnosis was 57.5 years for Filipino women and 60.8 years for White women (p < 0.0001). Filipino women had more high-grade and larger tumors than White women and were more likely to have node-positive disease. Among women with Stage I-IIIC breast cancer, the crude 10-year breast cancer-specific survival rate was 91.0% for Filipino and 88.9% for White women (HR 0.81, 95% CI 0.74-0.88, p < 0.01). In a propensity-matched analysis, the HR was 0.73 (95% CI 0.66-0.81). The survival advantage for Filipino women was present in subgroups defined by age of diagnosis, nodal status, estrogen receptor status, and HER2 receptor status.

CONCLUSION

In the United States, Filipino women often present with more advanced breast cancers than White women, but experience better breast cancer-specific survival.

Racial and Ethnic Disparities in Survival Among People With Second Primary Cancer in the US

Importance

Comprehensive data for racial and ethnic disparities after second primary cancers (SPCs) are lacking despite the growing burden of SPCs.

Objective

To quantify racial and ethnic disparities in survival among persons with SPCs.

Design, Setting, and Participants

This population-based, retrospective cohort study used data from 18 Surveillance, Epidemiology, and End Results registries in the US for persons diagnosed with the most common SPCs at age 20 years or older from January 1, 2000, to December 31, 2013 (with follow-up through December 31, 2018). Data were analyzed between January and April 2023.

Exposure

Race and ethnicity (Hispanic, non-Hispanic Asian or Pacific Islander, non-Hispanic Black, and non-Hispanic White).

Main Outcomes and Measures

The main outcomes were 5-year relative survival and cause-specific survival. Cause-specific hazard ratios (HRs) were calculated for death from cancer or cardiovascular disease (CVD) in each racial and ethnic minority population compared with the White population overall and stratified by SPC type, with adjustment for sex, year and age at SPC diagnosis, and prior cancer type and stage (baseline model) and additionally for county attributes (household income, urbanicity), SPC characteristics (stage, subtype), and treatment.

Results

Among 230 370 persons with SPCs (58.4% male), 4.5% were Asian or Pacific Islander, 9.6% were Black, 6.4% were Hispanic, and 79.5% were White. A total of 109 757 cancer-related deaths (47.6%) and 18 283 CVD-related deaths (7.9%) occurred during a median follow-up of 54 months (IQR, 12-93 months). In baseline models, compared with the White population, the risk of cancer-related death overall was higher in the Black (HR, 1.21; 95% CI, 1.18-1.23) and Hispanic (HR, 1.10; 95% CI, 1.07-1.13) populations but lower in the Asian or Pacific Islander population (HR, 0.93; 95% CI, 0.90-0.96). When stratified by 13 SPC types, the risk of cancer-related death was higher for 10 SPCs in the Black population, with the highest HR for uterine cancer (HR, 1.87; 95% CI, 1.63-2.15), and for 7 SPCs in the Hispanic population, most notably for melanoma (HR, 1.46; 95% CI, 1.21-1.76). For CVD-related death, the overall HR was higher in the Black population (HR, 1.41; 95% CI, 1.34-1.49), with elevated risks evident for 11 SPCs, but lower in the Asian or Pacific Islander (HR, 0.75; 95% CI, 0.69-0.81) and Hispanic (HR, 0.90; 95% CI, 0.84-0.96) populations than in the White population. After further adjustments for county attributes and SPC characteristics and treatment, HRs were reduced for cancer-related death and for CVD-related death and associations in the same direction remained.

Conclusions and Relevance

In this cohort study of SPC survivors, the Black population had the highest risk of both death from cancer and death from CVD, and the Hispanic population had a higher risk of death from cancer than the White population. Attenuations in HRs after adjustment for potentially modifiable factors highlight opportunities to reduce survival disparities among persons with multiple primary cancers.

Disease characteristics and mortality among Asian women with breast cancer

BACKGROUND

Asian women with breast cancer are often studied in aggregate, belying significant intragroup diversity. The authors sought to examine differences in breast cancer characteristics and outcomes among Asian women.

METHODS

Asian, non-Hispanic Black, Hispanic, and non-Hispanic White women aged 18 years and older who were diagnosed with breast cancer from 1990 to 2016 were identified in the Surveillance, Epidemiology, and End Results 18 database. Asian patients were subclassified as Chinese, Japanese, Korean, Filipino, Vietnamese, South Asian (Asian Indian or Pakistani), Southeast Asian (SEA, i.e., Cambodian, Laotian, Hmong, or Thai), or other Asian. Unadjusted overall survival (OS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Cox proportional hazards models were used to estimate adjusted OS and CSS.

RESULTS

In total, 910,415 women were included (Asian, n = 63,405; Black, n = 92,226; Hispanic, n = 84,451; White, n = 670,333). Asian women had higher rates of human epidermal growth factor receptor 2 (HER2)-positive disease compared with White women (18.7% vs 13.8%) and had the highest 10-year unadjusted OS and CSS among all racial/ethnic groups (all P < .001). SEA women had the highest rates of stage IV disease at presentation, whereas Japanese women had the lowest rates (5.9% vs 2.7%; P < .001). Japanese women had the highest 10-year unadjusted CSS (89.4%; 95% confidence interval, 88.7%-90.1%) of any distinct Asian group, whereas SEA women had the worst unadjusted CSS (78%; 95% confidence interval, 74.1%-81.3%; P < .001). After adjustment, SEA women had the worst OS of any Asian group and were the only Asian group without improved OS compared with White women (reference category; P = .08).

CONCLUSIONS

Breast cancer characteristics and outcomes vary significantly among Asian women. Future research should consider disaggregation by country or region of origin to identify subgroups that are at risk for worse outcomes than aggregated data may suggest.

LAY SUMMARY

Asian women with breast cancer are frequently studied as a single entity. However, Asian ethnic groups differ greatly by country of origin, genetic ancestry, disease frequency, socioeconomic status, patterns of immigration, as well as dietary and cultural practices. Women of different Asian ethnicities vary significantly with regard to cancer characteristics, such as mortality and tumor subtype. Future research should disaggregate these populations to better understand, treat, and counsel Asian patients with breast cancer.

Inequity in Cardio-Oncology: Identifying Disparities in Cardiotoxicity and Links to Cardiac and Cancer Outcomes

Minority and underresourced communities experience disproportionately high rates of fatal cancer and cardiovascular disease. The intersection of these disparities within the multidisciplinary field of cardio‐oncology is in critical need of examination, given the risk of perpetuating health inequities in the growing vulnerable population of patients with cancer and cardiovascular disease. This review identifies 13 cohort studies and 2 meta‐analyses investigating disparate outcomes in treatment‐associated cardiotoxicity and situates these data within the context of oncologic disparities, preexisting cardiovascular disparities, and potential system‐level inequities. Black survivors of breast cancer have elevated risks of cardiotoxicity morbidity and mortality compared with White counterparts. Adolescent and young adult survivors of cancer with lower socioeconomic status experience worsened cardiovascular outcomes compared with those of higher socioeconomic status. Female patients treated with anthracyclines or radiation have higher risks of cardiotoxicity compared with male patients. Given the paucity of data, our understanding of these racial and ethnic, socioeconomic, and sex and gender disparities remains limited and large‐scale studies are needed for elucidation. Prioritizing this research while addressing clinical trial inclusion and access to specialist care is paramount to reducing health inequity.

Survival Differences in Chinese Versus White Women With Breast Cancer in the United States: A SEER-Based Analysis

PURPOSE

The affect of race on breast cancer prognosis is not well understood. We compared crude and adjusted breast cancer survival rates of Chinese women versus White women in the United States.

METHODS

We conducted a cohort study of Chinese and White women with breast cancer diagnosed between 2004 to 2015 in the SEER 18 registries database. We abstracted information on age at diagnosis, tumor size, grade, lymph node status, receptor status, surgical treatment, receipt of radiotherapy and chemotherapy, and death. We compared crude breast cancer–specific mortality between the two ethnic groups. We calculated adjusted hazard ratios (HRs) in a propensity-matched design using the Cox proportional hazards model. P < .05 was considered statistically significant.

RESULTS

There were 7,553 Chinese women (1.8%) and 414,618 White women (98.2%) with stage I-IV breast cancer in the SEER database. There were small differences in demographics, nodal burden, and clinical stage between Chinese and White women. Ten-year breast cancer–specific survival was 88.8% for Chinese women and 85.6% for White women (HR, 0.73; 95% CI, 0.67 to 0.80; P < .0001). In a propensity-matched analysis among women with stage I–IIIC breast cancer, the HR was 0.71 (95% CI, 0.62 to 0.81; P < .0001). Annual mortality rates in White women exceeded those in Chinese women for the first 9 years after diagnosis.

CONCLUSION

Chinese women in the United States have superior breast cancer–specific survival compared with White women. The reason for the observed difference is not clear. Differences in demographic and tumor features between Chinese and White women with breast cancer may contribute to the disparity, as may the possibility of intrinsic biologic differences.

Risks of Second Primary Gynecologic Cancers following Ovarian Cancer Treatment in Asian Ethnic Subgroups in the United States, 2000-2016

BACKGROUND

The differential occurrence of second primary cancers by race following ovarian cancer is poorly understood. Our objective was to determine the incidence of second primary gynecologic cancers (SPGC) following definitive therapy for ovarian cancer. Specifically, we aimed to determine differences in SPGC incidence by Asian ethnic subgroups.

METHODS

We identified 27,602 women ages 20 years and older and diagnosed with first primary epithelial ovarian cancer between 2000 and 2016 who received surgery and chemotherapy in 18 population-based Surveillance, Epidemiology and End Results Program registries. We compared the incidence of SPGC with expected incidence rates in the general population of women using estimated standardized incidence ratios (SIR) and 95% confidence intervals (CI).

RESULTS

The incidence of SPGC was lower among White women (SIR = 0.73; 95% CI, 0.59-0.89), and higher among Black (SIR = 1.80; 95% CI, 0.96-3.08) and Asian/Pacific Islander (API) women (SIR = 1.83; 95% CI, 1.07-2.93). Increased risk of vaginal cancers was observed among all women, although risk estimates were highest among API women (SIR = 26.76; 95% CI, 5.52-78.2) and were also significant for risk of uterine cancers (SIR = 2.53; 95% CI, 1.35-4.33). Among API women, only Filipinas had significantly increased incidence of SPGC overall including both uterine and vaginal cancers.

CONCLUSIONS

Risk of SPGC following treatment of ovarian cancer differs by race and ethnicity, with Filipina women having the highest rates of second gynecologic cancers among Asian women.

IMPACT

Ensuring access and adherence to surveillance may mitigate ethnic differences in the early detection and incidence of second gynecologic cancers.

The long-term effect of age on cardiovascular disease in patients with breast cancer who received chemotherapy

PURPOSE

As breast cancer survival has significantly improved and patient life expectancy has increased, greater numbers of elderly breast cancer survivors are at risk for cardiovascular disease (CVD). Therefore, this study investigated the impact of age on the incidence, mortality, and predictors of CVD following adjuvant chemotherapy in the late period of survivorship.

METHODS

761 Patients who underwent chemotherapy were enrolled and divided into patients aged < 50 years (n = 413, 54.3%) and patients aged ≥ 50 years (n = 348, 45.7%). Among the entire cohort, 445 patients underwent transthoracic echocardiography.

RESULTS

During long-term follow-up (median 122 months, range 12-340 months), CVD events developed in 50 (6.57%) patients, including 17 (4.1%) aged < 50 years and 33 (9.5%) aged ≥ 50 years (p = 0.003). 8 (1.1%) of 50 patients with CVD died, including 1 patient aged < 50 years and 7 patients aged ≥ 50 years. CVD-free survival was significantly lower in patients aged ≥ 50 years compared with patients aged < 50 years (p < 0.001). In multivariate analyses, age ≥ 50 years [p < 0.001, hazard ratio (HR) = 3.802, 95% confidence interval (CI) 1.986-7.278], the radio of the peak early and mitral tissue Doppler velocities (p = 0.014, HR = 1.102, 95% CI 1.020-1.190), and global longitudinal strain (p < 0.001, HR = 1.208, 95% CI 1.096-1.332) are significant predictors of CVD.

CONCLUSIONS

Age, diastolic function, and strain value in patients with breast cancer who underwent chemotherapy has a long-term effect on CVD. Therefore, it is important to consider ethnic and age-specific risks for CVD in breast cancer survivors.

Ethnic differences in cardiovascular morbidity and mortality among patients with breast cancer in the Netherlands: a register-based cohort study

OBJECTIVES

Cardiovascular disease (CVD) is of increasing concern among breast cancer survivors. However, evidence on ethnic differences in CVD among women with breast cancer is sparse. We assessed ethnic differences in cardiovascular morbidity and mortality among patients with breast cancer in the Netherlands.

METHODS

A nationwide register-based cohort study comprising all women with a first admission for breast cancer (n=127 714) between 1996 and 2010 in the Netherlands was conducted. Differences in CVD admission, CVD mortality and overall CVD event, which comprised a CVD admission and/or CVD mortality, between the largest ethnic minority groups (Surinamese, Moroccan, Turkish, Antillean and Indonesian) and the Dutch general population (henceforth, Dutch) were investigated using Cox proportional hazard models.

RESULTS

The incidence of cardiovascular outcomes varied by the ethnic group. The incidence of an overall cardiovascular event was significantly higher for women with breast cancer from Suriname (HR 1.46; 95% CI 1.29 to 1.64) and Turkey (HR 1.25; 95% CI 1.03 to 1.51), compared with Dutch women with breast cancer. In contrast, Indonesian women with breast cancer had a significantly lower risk (HR 0.88; 95% CI 0.81 to 0.96) of a cardiovascular event compared with Dutch women with breast cancer. The risk of a cardiovascular event did not differ between Moroccan and Dutch women with breast cancer, whereas for Antillean women the risk was not significantly higher.

CONCLUSIONS

Our findings suggest that Surinamese and Turkish women with breast cancer are disadvantaged in terms of cardiovascular outcomes compared with Dutch women with breast cancer. More work is needed to unravel the potential factors contributing to these differences.

Feasibility of a Multicomponent Breast Health Education Intervention for Vietnamese American Immigrant Women

PURPOSE/OBJECTIVES

To determine the feasibility and acceptability of an intervention with targeted cultural and health belief messages to increase rates of mammography among Vietnamese American (VA) immigrant women. 
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DESIGN

One-group, pre-/post-test, pilot, quasiexperimental design.
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SETTING

Portland, Oregon, metropolitan area. 
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SAMPLE

40 VA immigrant women aged 50 years or older.
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METHODS

Participants who had not had a mammogram within the past 12 months were recruited. The intervention consisted of one interactive group teaching session, followed by individual counseling delivered about 10 days later to overcome barriers to screening. Participants completed a baseline survey prior to the group teaching and again at 12 weeks after the session.
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MAIN RESEARCH VARIABLES

The intervention, guided by the Transtheoretical Model of Change and the Health Belief Model, involved movement in stage of change based on women's readiness, as well as perceived susceptibility, perceived benefits, perceived common barriers, and perceived cultural barriers. Mammogram completion and knowledge of breast cancer and mammography were examined.
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FINDINGS

The recruitment response rate was 58%. Knowledge about breast cancer, breast cancer susceptibility, and the benefits of mammography as related to breast cancer significantly increased following the intervention.
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CONCLUSIONS

Acceptability of the targeted program, good feasibility, and very low attrition was achieved. 
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IMPLICATIONS FOR NURSING

This intervention can be adapted for other populations, including other Asian groups, and other cancer screenings.

Vietnamese American Women's Beliefs and Perceptions About Breast Cancer and Breast Cancer Screening: A Community-Based Participatory Study

INTRODUCTION

Although breast cancer (BC) rates are declining in White non-Hispanic American women, they are increasing among Vietnamese American women (VAW) at 1.2% (95% confidence interval [0.1, 2.2]) per year. BC screening rates (64%) are below the national rates (81.1%). This article explores VAW's beliefs about BC and screening.

METHOD

Using community-based participatory qualitative descriptive methods, 40 VAW were recruited from Oregon, and four focus groups were conducted. A directed content analysis was used.

RESULTS

Main themes were as follows: deferred to a health care provider or relying on self-detection and symptoms; fear of BC versus fear of procedural pain; limited knowledge; motivation by observing others' journey in BC death or survivorship; body image concern; "living carefree," "good fortune-having good health"; and coverage for a mammogram expense means health care access.

DISCUSSION

Tailored interventions should address mammogram knowledge, fear, erroneous information, body image, fate and luck, and promoting access.

Risk of death from cardiovascular disease following breast cancer: a systematic review

Purpose

Breast cancer incidence and survival is high, which results in high prevalence of breast cancer survivors. The risk of (death from) cardiovascular disease (CVD) is higher in patients exposed to cardiotoxic treatments, in particular if they have pre-existing CVD risk factors. This study systematically summarized the risk of death from CVD following breast cancer.

Methods

Databases of Medline, Embase, and the Cochrane Library were systematically searched using the following terms and synonyms: breast cancer, cardiovascular disease, and cause of death. Articles reporting on both risk and risk factors of CVD mortality following breast cancer were eligible for inclusion. The methodological quality of each article was assessed using the Newcastle Ottawa quality assessment scale for cohort studies.

Results

Fourteen articles were included assessing the risk of CVD mortality among 1,217,910 women with breast cancer. The methodological quality was high for the majority of the studies. Studies were heterogeneous in design, study population, length of follow-up, CVD outcomes, and risk factors. 1.6–10.4% of all women with breast cancer died of CVD. Women with breast cancer had a higher risk of CVD mortality than women from the general population. The risk of CVD mortality was higher among women with breast cancer with older age at diagnosis, left-sided tumor, diagnosis in an earlier calendar period, and black ethnic origin.

Conclusions

CVD is an important cause of death following breast cancer. Identification of patients at high risk of CVD is important to optimize CVD prevention and tailor breast cancer treatment.