Female Breast Cancer Trends in Disaggregated Asian American Populations: Analysis of 2003-2017 U.S. Mortality Data

Female Breast Cancer Trends in Disaggregated Asian American Populations: Analysis of 2003-2017 U.S. Mortality Data | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Female Breast Cancer Trends in Disaggregated Asian American Populations: Analysis of 2003-2017 U.S. Mortality Data Vaishnavi Bhamidi, Nathaniel Islas, Caroline Feng, Naveli Garg, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-416046/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 5 You are reading this latest preprint version Abstract Purpose Breast cancer is the second leading cause of female cancer mortality in the United States and breast cancer mortality in Asian Americans (AA) is rising by 1.5% per year. However, aggregated AA breast cancer death rates may mask important mortality differences in major AA groups. Population & Setting 11,388 AA and 473,927 non-Hispanic White (NHW) females based on the United States Centers for Disease Control and Prevention National Vital Statistics System database 2003-2017. Methods Age-adjusted mortality rates (AAMR) were used to estimate trends in breast cancer mortality in Asian Indians, Chinese, Filipinas, Japanese, Koreans, Vietnamese, and non-Hispanic Whites from 2003–2017, with attention to annual percentage change (APC) and proportional mortality rates (PMR). Results From 2003-2017, breast cancer deaths comprised 14.4% in NHWs, 13.7% in aggregate AAs, 19.8% in Asian Indians, and 18.6% of all cancer deaths in Filipinas. While NHW breast cancer mortality rate significantly decreased (APC -2.1; CI -2.6, -1.6; p < 0.001) from 2003 to 2017, aggregate AA mortality rates were unchanged (APC 3.07; CI -0.37, 7.8; p = 0.071). However, when disaggregated, breast cancer mortality in Filipina (APC 1.9; CI 0.8, 3.0; p < 0.002), Chinese (APC 2.1; CI 1.3, 3.0; p < 0.001), and Korean (APC 2.6; CI 1.0, 4.1; p = 0.004) women significantly increased. Breast cancer mortality rates in Japanese women decreased (APC -1.9; CI -5.9, 2.1; p = 0.3). Conclusion While the proportion of women dying from breast cancer were similar in NHWs and aggregate Asians, when disaggregated, Filipina, Korean, and Chinese women had increased mortality rates over the past 15 years. During this time, breast cancer mortality in NHW and Japanese women decreased. Understanding disaggregated breast cancer mortality rates in Asians may improve culturally-tailored outreach, prevention, and treatment strategies to reduce cancer deaths from this critical disease. Oncology Breast cancer Non-Hispanic White (NHW) Age-adjusted mortality rates (AAMR) proportional mortality rates (PMR). Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction In the United States, 1 in 8 women (12%) will be diagnosed with invasive breast cancer in their lifetime and 1 in 39 women (3%) will die due to breast cancer 1 . Efforts such as emerging treatments and more aggressive screening practices have significantly reduced breast cancer mortality by 40% from 1989 to 2017 1 . Despite this progress, breast cancer is still predicted to be the leading form of new cancer diagnosed in 2020 and will account for 30% of all predicted cancer cases in all American females 2 . When aggregated, women with Asian/Pacific Islander ancestry appear to have the lowest breast cancer incidence (93.7 per 100,000) and death (14 per 100,000) rates of all American racial groups 1 , but the aggregate Asian American (AA) breast cancer incidence has been increasing by 1.5% yearly 3,4 . With over 17.3 million AAs in the U.S. in 2010, this rate of increase in breast cancer indicates a significant healthcare burden 5 , 6 . The distinct ethnic subgroups comprising the AA population are extremely diverse in country of origin, length of US residence, acculturation, socioeconomic status, language, culture, religion, and more 7 – 10 . By aggregating all AAs into a single group, health care providers and policy makers may miss critical heterogeneity around breast cancer healthcare and mortality 11 . For example, Thompson et al. examined disaggregated death certificate data of AAs (Asian Indian, Korean, Japanese, Chinese, Vietnamese, and Filipino) from 2003 to 2011 and found that female Filipino Americans had the highest comparative rates of breast cancer amongst the six AA ethnic groups, even if the aggregated AA death rates trended downward 12 . However, this study did not find any significant breast cancer mortality trends for any of the AA groups. In this study, we present updated trends in female breast cancer mortality rates from 2012 to 2017 among six disaggregated AA ethnicities in comparison with Non-Hispanic White (NHW) females using the Centers for Disease Control and Prevention (CDC) National Vital Statistics System (NVSS) mortality dataset. We also compare current breast cancer mortality trends to previous trends from 2003 to 2011. Methods Data U.S. mortality records between 2003 to 2017 for all fifty states were obtained under an IRB data-use agreement from the CDC NVSS mortality dataset (Protocol # 53429). Death certificates were completed by clinicians and/or medical coroners at time of death and include information about age, sex, race/ethnicity, and cause of death. Underlying causes of death were classified by the International Classification of Diseases (ICD), 10th revision. ICD-10 code C50 (malignant neoplasm of the breast) identified breast cancer as the primary underlying cause of death. Other variables of interest included sex and age. Participants Female NHWs and AAs within six ethnic groups were included: Asian Indians, Chinese, Filipinos, Japanese, Koreans, Vietnamese. Hispanics, African American or Black, Pacific Islanders, and any AAs not in the six selected subgroups were excluded. Males were also excluded from the study. Incomplete death certificates (decedents with missing data for age and primary cause of death variables) and individuals with mixed racial identity or unknown age were excluded. Data analysis was conducted for 473,927 NHW females and 11,388 AA females (1425 Asian Indians, 2898 Chinese, 3865 Filipina, 1549 Japanese, 949 Korean, 702 Vietnamese) (Fig. 1 ). Statistical Analysis Three different numerical measures were calculated: age-adjusted mortality rates (AAMR), standardized mortality ratios (SMR), and proportionate mortality. AAMR was calculated as the deaths per 100,000 people. Annual percentage change (APC) was calculated as the average percentage change in the fifteen-year period. SMR was calculated as a ratio of the AAMRs with NHW as the reference. Proportionate mortality was calculated as the proportion of breast cancer deaths compared to all cancer deaths. Population counts were extrapolated based on the 2003 and 2010 US Census. To account for the rolling adoption of the 2003 death certificate by state, population adjustment was conducted by enrolling descendants from each state as disaggregated information became available 13 . Death and population data from each state were included in the numerator and denominator, respectively, when that state adopted the 2003 death certificate. For AAMRs from 2003–2017, age adjustment was calculated using the 2010 US standard age distribution of the population. The same standard age distribution was applied to each group's age-specific mortality rates in order to compare groups. Nativity population data for each of the six AA subgroups was gathered from the American Community Survey (ACS) 14 . We did not suppress data with < 10 deaths per cell. A linear model, and not a joinpoint analysis, to analyze the overall trend. Results Results for Aggregate AAs We identified 624,221 female AA decedents and 30,269,449 female NHW decedents over the fifteen-year study period, of whom 612,833 female AAs and 30,222,057 female NHWs were excluded and 11,388 female AAs and 473,927 female NHWs died of breast cancer (Supplementary Fig. 1). Overall, 13.7% of aggregate female AA and 14.4% female NHW cancer deaths were from breast cancer. AAMRs within disaggregated female AAs ranged from 3.5 per 100,000 (Vietnamese) to 21.6 per 100,000 (Filipina) (Fig. 2 and Supplementary Fig. 2). Results for Disaggregated AAs Breast cancer death rates over time : Temporal AAMR rates demonstrated a significant decrease in NHW breast cancer mortality (APC − 2.11; CI -2.63 -1.60; p < 0.001) while breast cancer mortality in aggregate AAs was AAs was increasing, but not significantly (APC 3.07; CI -0.37 6.50; p < 0.05) (Fig. 2 and Supplementary Fig. 2). However, when AAs were disaggregated, Filipinas consistently had the highest AAMR rates, while Japanese women had the lowest rates (Fig. 2 and Supplementary Fig. 2). In addition, Filipinas had a significantly increasing trend (APC 1.75; CI 0.98 2.53; p < 0.001), as did Chinese (APC 2.00; CI 1.06 2.92; p < 0.001) and Korean (APC 1.98; CI 0.58 3.36, p < 0.01) women. Japanese women had an insignificant decreasing breast cancer mortality trend (APC − 1.88; CI -5.88 2.1, p = 0.33). Asian Indians (APC − 0.06; CI -2.25 2.37; p = 0.96) and Vietnamese women (APC 1.72; CI -0.01 3.45; p = 0.05) had stable breast cancer mortality rates with no significant trends. Proportion of breast cancer deaths : Although proportionate mortality of breast cancer deaths compared to all cancer deaths for aggregate AAs (13.7%) and NHWs (14.4%) appear comparable, the disaggregated AA ethnicities show great variability (Fig. 4 ). Asian Indians (19.8%) and Filipinas (18.6%) had the highest proportion of breast cancer deaths, as well as NHWs (14.4%). On the other end, Korean (10.0%), Japanese (10.7%), and Vietnamese women (10.5%) had the lowest proportion of breast cancer mortality. Nativity Analysis An analysis of breast cancer mortality trends from 2003–2017 for each of the six Asian groups showed no significant differences by place of birth, except for Japanese women (Fig. 5 ). US-born Japanese women had decreasing rates of breast cancer deaths (APC − 1.0; CI -1.7 -2.4; p 0.0001), while breast cancer deaths increased in foreign-born Japanese (APC 11.4; CI 0.8 6.12; p 0.02) (Fig. 6 and Supplementary Fig. 3). Discussion Over the past 15 years, we found that non-Hispanic white women have exhibited steadily decreasing breast cancer mortality trends (about 2.1% annually), while the aggregate Asian Americans breast cancer deaths have remained stable. However, when AAs groups are disaggregated, they demonstrate considerable heterogeneity. Specifically, we found that Filipina, Korean and Chinese women have about a 2% annual increase in breast cancer deaths. Moreover, Filipina women had the highest age-adjusted breast cancer rates which were about two times higher than aggregate AAs. By contrast, Vietnamese, Asian Indians, and aggregated AAs exhibited a stable breast cancer mortality trend. While aggregated proportions of cancer deaths were the same for NHW and AA (about 14%), when disaggregated, AA groups demonstrated broad variability in mortality. The large variability in breast cancer mortality rates by AA groups corresponds to results from earlier studies. Thompson et al., found that Filipinas had the highest rate of breast cancer, contributing to 19.5% of all Filipina cancer deaths 12 . They also found 19.8% of all Asian Indian cancer deaths were from breast cancer, now the leading cause of all Asian Indian cancer deaths. These findings might be influenced by cancer type, hormone therapy, access to care, screening and lifestyle behaviors amongst women within each AA group. High but stable breast cancer mortality in Asian Indian women and low but stable mortality in Vietnamese women may be influenced by cancer type. Asian Indians are more likely than NHWs to have triple-negative breast cancer 15 – 17 , which is relatively uncommon and, until recently, without curative targeted therapies 18 – 19 . Conversely, Vietnamese women are more likely to have HER2-positive breast cancer 20 , which can have a poor prognosis if not treated optimally with targeted therapies 21 . The stable breast cancer mortality among Asian Indian and Vietnamese women may also be influenced by access to care 22 . Increasing AA breast cancer mortality may be driven by post-menopausal hormone replacement therapy (HRT) 23 . Breast cancer risk increased 26% per 5 years of current use of estrogen and progestin therapy (p = 0.017) in a study of 1,277 Chinese, Japanese, and Filipinas 24 . Asian and Pacific Islander postmenopausal women may be at higher risk for developing breast cancer (OR 1.58; 95% CI of 1.18–2.11) than NHW women (OR 1.21; 95% CI 1.14–1.28) after using HRT 25 . Increasing breast cancer mortality in Filipina, Chinese, and Korean women may be due to lack of preventative public health measures, including screening 26 – 28 and treatment 29 . AA cancer screening rates are lower than those of NHWs for all cancer types 30 and AA women (65%) tend to have lower breast cancer screening rates than NHWs (68%) 31 . In a study comparing mammography rates among AA subgroups, South Asian and Korean women had the lowest mammography rates while Japanese women had the highest rates, second only to NHW women 7 . By contrast, Korean American women had the lowest rates of breast cancer screening 32 . Acculturation, healthcare access, and low levels of health literacy have been posited as potential reasons for reduced breast cancer screening in AAs 30,33−35 . Breast cancer screening rates also vary between the AA subgroups 26 . Lower levels of screening, perhaps coupled with an increase in risk factors associated with a Western lifestyle (e.g., obesity, alcohol, tobacco, unopposed continuous estrogen from reduced and/or delayed parity) may contribute to increasing breast cancer mortality trends within Korean women. In addition, screening behaviors vary by Asian American group. A meta-analysis found that only 34–65% of Korean women aged 50–74 reported obtaining a mammogram within the last two years, compared to 73% of white women and 72% of other Asian women 36 . Mammography screening among Korean American women in the past two decades has also significantly increased, but these rates are still much lower than NHWs, especially since Korean American women tended to be uninsured and sought out professionals from South Korea where preventative health measures are unusual 26 . Consistent with their lower utilization of mammography screening, Korean women were twice as likely to be diagnosed with a tumor size > 1 cm as compared to White women (OR 2.38; CI 1.49 3.80) 37 . Amongst Asians, Japanese women had the lowest rates of breast cancer mortality. Not only have Japanese American women been shown to have increased mammography rates compared to other Asians 38 , Japanese American women with breast cancer also had a lower risk of having advanced-stage disease than NHW women or those in other Asian subgroups 39 . Increased adoption of breast screening among Japanese may be driven by a larger proportion of acculturated, highly educated, and wealthier Japanese American women as compared by other AA ethnicities 8 , 40 . Our study has several limitations. While we captured all deaths in the United States, ethnic/racial groups may have been misclassified unintentionally by the healthcare provider or funeral director completing the death certificate, especially if next-of-kin or family members were not present 41 . However, ethnicity misclassification has been diminishing over time, and are estimated at 3% for Asian Pacific Islanders 41 . States’ adoption of the 2003 death certificate Asian subgroup classification occurred over time, although the states with the largest Asian populations were among the earlier adopters 13 . Finally, as death certificate data are not linked to other medical information, no information is available about other socioeconomic data that might inform further mortality-related analysis. Conclusion Breast cancer mortality may be improved with healthy lifestyles, early diagnosis via mammographic screening, tailored treatment, and ongoing follow-up. The high and often increasing rates of breast cancer mortality among specific Asian American groups point to the need to disaggregate AA subgroups during research studies, to ensure that potential disparities in access to effective screening, treatment and follow-up care do not go unnoticed and unresolved. Declarations Funding This study was funded and supported by the Stanford Center for Asian Health Research and Education, Palo Alto, CA. Conflicts of Interest The authors have no conflicts of interest to declare that are relevant to the content of this article. Availability of Data and Material The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request Code Availability R Studio, Version 3.6.1 References American Cancer Society. Breast Cancer Facts & Figures 2019-2020. Atlanta: American Cancer Society, Inc. 2019. American Cancer Society. Cancer Facts & Figures 2020. Atlanta: American Cancer Society; 2020. DeSantis CE, Ma J, Gaudet MM, et al. Breast cancer statistics, 2019. CA A Cancer J Clin. 2019;69(6):438-451. doi:10.3322/caac.21583 Gomez SL, Noone A-M, Lichtensztajn DY, et al. Cancer Incidence Trends Among Asian American Populations in the United States, 1990–2008. J Natl Cancer Inst. 2013;105(15):1096-1110. doi:10.1093/jnci/djt157 Hoeffel EM, Rastogi S, Kim MO, Shahid H. The Asian Population: 2010. Wu AH, Stram DO, Hamilton AS. Resources and Methods for Studying Cancer Among Asian Americans. In: Cancer Epidemiology Among Asian Americans. Springer International Publishing; 2016. doi:10.1007/978-3-319-41118-7 McCracken M, Olsen M, Chen MS, et al. Cancer Incidence, Mortality, and Associated Risk Factors Among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese Ethnicities. CA: A Cancer Journal for Clinicians. 2007;57(4):190-205. doi:10.3322/canjclin.57.4.190 Pew Research Center. The Rise of Asian Americans. Washington, DC: Pew Research Center; 2012. Asian American Center for Advancing Justice. A Community of Contrasts–Asian Americans in the United States: 2011. Washington, DC: Asian American Center for Advancing Justice; 2011:1–68. Torre LA, Goding Sauer AM, Chen MS, Kagawa-Singer M, Jemal A, Siegel RL. Cancer Statistics for Asian Americans, Native Hawaiians, and Pacific Islanders, 2015: Convergence of incidence between males and females. CA Cancer J Clin. 2016;66(3):182-202. doi:10.3322/caac.21335 Srinivasan S, Guillermo T. Toward improved health: disaggregating Asian American and Native Hawaiian/Pacific Islander data. Am J Public Health. 2000;90(11):1731-1734. doi:10.2105/AJPH.90.11.1731 Thompson CA, Gomez SL, Hastings KG, et al. The Burden of Cancer in Asian Americans: A Report of National Mortality Trends by Asian Ethnicity. Cancer Epidemiology Biomarkers & Prevention. 2016;25(10):1371-1382. doi:10.1158/1055-9965.EPI-16-0167 Thompson CA, Boothroyd DB, Hastings KG, Cullen MR, Palaniappan LP, Rehkopf DH. A Multiple-Imputation “Forward Bridging” Approach to Address Changes in the Classification of Asian Race/Ethnicity on the US Death Certificate. American Journal of Epidemiology. 2018;187(2):347-357. doi:10.1093/aje/kwx215 Steven Ruggles, Sarah Flood, Ronald Goeken, Josiah Grover, Erin Meyer, Jose Pacas and Matthew Sobek. IPUMS USA: Version 10.0. Minneapolis, MN: IPUMS, 2020. https://doi.org/10.18128/D010.V10.0 Kakarala M, Rozek L, Cote M, Liyanage S, Brenner DE. Breast cancer histology and receptor status characterization in Asian Indian and Pakistani women in the U.S. - a SEER analysis. BMC Cancer. 2010;10(1):191. doi:10.1186/1471-2407-10-191 Parise C, Caggiano V. Disparities in the risk of the ER/PR/HER2 breast cancer subtypes among Asian Americans in California. Cancer Epidemiology. 2014;38(5):556-562. doi:10.1016/j.canep.2014.08.001 Denkert C, Liedtke C, Tutt A, Von Minckwitz G. Molecular alterations in triple-negative breast cancer—the road to new treatment strategies. The Lancet. 2017;389(10087):2430-2442. doi:10.1016/S0140-6736(16)32454-0 McCann KE, Hurvitz SA, McAndrew N. Advances in Targeted Therapies for Triple-Negative Breast Cancer. Drugs. 2019;79(11):1217-1230. doi:10.1007/s40265-019-01155-4 Telli ML, Chang ET, Kurian AW, et al. Asian ethnicity and breast cancer subtypes: a study from the California Cancer Registry. Breast Cancer Res Treat. 2011;127(2):471-478. doi:10.1007/s10549-010-1173-8 Arteaga CL, Sliwkowski MX, Osborne CK, Perez EA, Puglisi F, Gianni L. Treatment of HER2-positive breast cancer: current status and future perspectives. Nature Reviews Clinical Oncology. 2012;9(1):16-32. doi:10.1038/nrclinonc.2011.177 Loibl S, Gianni L. HER2-positive breast cancer. The Lancet. 2017;389(10087):2415-2429. doi:10.1016/S0140-6736(16)32417-5 Gradishar WJ, Anderson BO, Abraham J, et al. Breast Cancer, Version 3.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2020;18(4):452-478. doi:10.6004/jnccn.2020.0016 Coombs NJ, Cronin KA, Taylor RJ, Freedman AN, Boyages J. The impact of changes in hormone therapy on breast cancer incidence in the US population. Cancer Causes Control. 2010;21(1):83-90. doi:10.1007/s10552-009-9437-5 Wu AH, Yu MC, Tseng C-C, Pike MC. Body size, hormone therapy and risk of breast cancer in Asian–American women. International Journal of Cancer. 2007;120(4):844-852. doi:https://doi.org/10.1002/ijc.22387 Hou N, Hong S, Wang W, Olopade OI, Dignam JJ, Huo D. Hormone replacement therapy and breast cancer: heterogeneous risks by race, weight, and breast density. J Natl Cancer Inst. 2013;105(18):1365-1372. doi:10.1093/jnci/djt207 Oh KM, Taylor KL, Jacobsen KH. Breast Cancer Screening Among Korean Americans: A Systematic Review. J Community Health. 2017;42(2):324-332. doi:10.1007/s10900-016-0258-7 Sadler GR, Wang K, Wang M, Ko CM. Chinese women: behaviors and attitudes toward breast cancer education and screening. Women’s Health Issues. 2000;10(1):20-26. doi:10.1016/S1049-3867(99)00046-8 Ko CM, Sadler GR, Ryujin L, Dong A. Filipina American women’s breast cancer knowledge, attitudes, and screening behaviors. BMC Public Health. 2003;3(1):27. doi:10.1186/1471-2458-3-27 Gelber RP, McCarthy EP, Davis JW, Seto TB. Ethnic Disparities in Breast Cancer Management Among Asian Americans and Pacific Islanders. Ann Surg Oncol. 2006;13(7):977-984. doi:10.1245/ASO.2006.08.036 Shi L, Lebrun LA, Zhu J, Tsai J. Cancer screening among racial/ethnic and insurance groups in the United States: a comparison of disparities in 2000 and 2008. J Health Care Poor Underserved. 2011;22(3):945-961. doi:10.1353/hpu.2011.0079 Ryu SY, Crespi CM, Maxwell AE. What Factors Explain Disparities in Mammography Rates Among Asian-American Immigrant Women? A Population-Based Study in California. Women’s Health Issues. 2013;23(6):e403-e410. doi:10.1016/j.whi.2013.08.005 Sentell T, Braun KL, Davis J, Davis T. Health literacy and meeting breast and cervical cancer screening guidelines among Asians and whites in California. Springerplus. 2015;4:432. doi:10.1186/s40064-015-1225-y Kandula NR, Wen M, Jacobs EA, Lauderdale DS. Low rates of colorectal, cervical, and breast cancer screening in Asian Americans compared with non-Hispanic whites. Cancer. 2006;107(1):184-192. doi:10.1002/cncr.21968 Lee S, Chen L, Jung MY, Baezconde-Garbanati L, Juon H-S. Acculturation and Cancer Screening Among Asian Americans: Role of Health Insurance and Having a Regular Physician. J Community Health. 2014;39(2):201-212. doi:10.1007/s10900-013-9763-0 Lee HY, Ju E, Vang PD, Lundquist M. Breast and Cervical Cancer Screening Disparity Among Asian American Women: Does Race/Ethnicity Matter? Journal of Women’s Health. 2010;19(10):1877-1884. doi:10.1089/jwh.2009.1783 Hedeen AN, White E, Taylor V. Ethnicity and birthplace in relation to tumor size and stage in Asian American women with breast cancer. Am J Public Health. 1999;89(8):1248-1252. doi:10.2105/AJPH.89.8.1248 McPherson K, Steel CM, Dixon JM. Breast cancer—epidemiology, risk factors, and genetics. BMJ. 2000;321(7261):624-628. Liu L, Zhang J, Wu AH, Pike MC, Deapen D. Invasive breast cancer incidence trends by detailed race/ethnicity and age. Int J Cancer . Published online 2012:10. Hou N, Hong S, Wang W, Olopade OI, Dignam JJ, Huo D. Hormone replacement therapy and breast cancer: heterogeneous risks by race, weight, and breast density. J Natl Cancer Inst. 2013;105(18):1365-1372. doi:10.1093/jnci/djt207 Access Versus Acculturation: Identifying Modifiable Factors to Promote Cancer Screening Among Asian American Women. Published online 2021:10. The Validity of Race and Hispanic-Origin Reporting on Death Certificates in the United States: An Update. Centers for Disease Control and Prevention; 2016:29. Supplementary Files SupplementaryFigure1.docx SupplementaryFigure2.docx SupplementaryFigure3.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Major revisions 01 Jul, 2021 Reviews received at journal 09 Jun, 2021 Reviewers invited by journal 24 May, 2021 Editor assigned by journal 12 Apr, 2021 First submitted to journal 11 Apr, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-416046","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":28971152,"identity":"13391b20-78f5-4677-ace5-906d02eeb72d","order_by":0,"name":"Vaishnavi Bhamidi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIie3PsYrCMBjA8UAg06ddW9KH+CAQkBR8lUCgtxTsIwiuiqvCPUxKh1vkuhZ6i7je5MEh6GCqq8S6OeQPCUnIjxBCQqF3LAY3IYXotsvcsO5wEEnm1C3ywYRQgnYowW5VHdtSpaJpqr9SZ7OxpVUHPvLzbXiBHyBbQ/lG55OtZUb5SLIp0JHaEUr46FQjWpD8CRHnnoh1Tc+gexL9e0kUF/L2ChLD+J0A85N0J1X/l7g1UoHOMamZmHx6CONL0RUXNY3W1aEDneH4a7Fvfz3kQfS166FQKBR60BUCukRdJR48CwAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-6317-6463","institution":"Stanford Center for Asian Health Research and Education","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Vaishnavi","middleName":"","lastName":"Bhamidi","suffix":""},{"id":28971153,"identity":"eb9fe742-59df-41b3-a82a-f106c9c94812","order_by":1,"name":"Nathaniel Islas","email":"","orcid":"","institution":"Stanford Center for Asian Health Research and Education","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nathaniel","middleName":"","lastName":"Islas","suffix":""},{"id":28971154,"identity":"e73352c2-923d-41ac-be62-2640df0ecaf0","order_by":2,"name":"Caroline Feng","email":"","orcid":"","institution":"Stanford Center for Asian Health Research and Education","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Caroline","middleName":"","lastName":"Feng","suffix":""},{"id":28971155,"identity":"3d679603-9d5b-4d6f-9523-f5f104b723fb","order_by":3,"name":"Naveli Garg","email":"","orcid":"","institution":"Stanford Center for Asian Health Research and Education","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Naveli","middleName":"","lastName":"Garg","suffix":""},{"id":28971156,"identity":"b253e863-8692-446a-9445-d474a7e05644","order_by":4,"name":"Kevin Xi","email":"","orcid":"","institution":"Stanford Center for Asian Health Research and Education","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kevin","middleName":"","lastName":"Xi","suffix":""},{"id":28971157,"identity":"1d5f18fd-95f7-475a-a021-3343426938e1","order_by":5,"name":"Robert Huang","email":"","orcid":"","institution":"Stanford University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Huang","suffix":""},{"id":28971158,"identity":"d81b86cd-1925-4b77-8511-44448b19572e","order_by":6,"name":"Timothy Au","email":"","orcid":"","institution":"Stanford Center for Asian Health Research and Education","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Timothy","middleName":"","lastName":"Au","suffix":""},{"id":28971159,"identity":"8f07d30b-9b38-4148-897e-a74bfc040535","order_by":7,"name":"Nora Sharp","email":"","orcid":"","institution":"Stanford Center for Asian Health Research and Education","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nora","middleName":"","lastName":"Sharp","suffix":""},{"id":28971160,"identity":"c36df04a-faeb-4a49-a036-03cf85788022","order_by":8,"name":"Allison W. Kurian","email":"","orcid":"","institution":"Stanford University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Allison","middleName":"W.","lastName":"Kurian","suffix":""},{"id":28971161,"identity":"e0902f02-5de2-4e9d-a62d-3f044200d748","order_by":9,"name":"Latha Palaniappan","email":"","orcid":"","institution":"Stanford University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Latha","middleName":"","lastName":"Palaniappan","suffix":""},{"id":28971162,"identity":"6c7dca86-f450-4d0f-8e3d-ebf09197ac3d","order_by":10,"name":"Sukyung Chung","email":"","orcid":"","institution":"Stanford University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sukyung","middleName":"","lastName":"Chung","suffix":""},{"id":28971163,"identity":"4f83dc75-bc54-4741-bf8c-61f72fcccce9","order_by":11,"name":"Caroline A. Thompson","email":"","orcid":"","institution":"San Diego State University Graduate School of Public Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Caroline","middleName":"A.","lastName":"Thompson","suffix":""},{"id":28971164,"identity":"352ed6d1-0891-47e8-9257-815a9d8cf12b","order_by":12,"name":"Malathi Srinivasan","email":"","orcid":"","institution":"Stanford University School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Malathi","middleName":"","lastName":"Srinivasan","suffix":""}],"badges":[],"createdAt":"2021-04-12 23:14:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-416046/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-416046/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":9682115,"identity":"e9f914df-b587-485d-8e28-b57b21913235","added_by":"auto","created_at":"2021-05-27 20:22:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":54324,"visible":true,"origin":"","legend":"Demographics of Asian American and non-Hispanic white female breast cancer decedents, National Vital Statistics System 2003-2017","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-416046/v1/3f2d246efe0ff9da57accee7.png"},{"id":9682117,"identity":"e6302c6b-36bf-4e22-82a7-9298ae778278","added_by":"auto","created_at":"2021-05-27 20:22:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":139533,"visible":true,"origin":"","legend":"Age-adjusted breast cancer mortality rates per 100,000 reported by Asian American group and non-Hispanic whites female breast cancer decedents, National Vital Statistics System 2003-2017","description":"","filename":"fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-416046/v1/b7759046eeb765773377e1b9.png"},{"id":9682120,"identity":"afc90409-7a7a-47ae-831f-e854f4b763f1","added_by":"auto","created_at":"2021-05-27 20:22:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":130966,"visible":true,"origin":"","legend":"Age-adjusted mortality ratio standardized by the age-adjusted mortality rate for Asian American and non-Hispanic Whites female breast cancer decedents, National Vital Statistics System 2003-2017, reference group American Community Survey 2010","description":"","filename":"fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-416046/v1/aeda2f156ac2707e51c7e923.png"},{"id":9682121,"identity":"add62418-2b09-43bf-992e-0ae89b20bac2","added_by":"auto","created_at":"2021-05-27 20:22:28","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":67535,"visible":true,"origin":"","legend":"Proportionate mortality of breast cancer compared to all cancer mortality in Asian American and non-Hispanic white women, National Vital Statistics System 2003-2017","description":"","filename":"fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-416046/v1/ba3099dec328fb52e8fe083f.png"},{"id":9682116,"identity":"aadc6d73-aebd-4398-a355-6c6e309707fb","added_by":"auto","created_at":"2021-05-27 20:22:28","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":74657,"visible":true,"origin":"","legend":"Total breast cancer deaths amongst Asian American groups, by nativity (US vs Foreign-born), National Vital Statistics System 2003-2017","description":"","filename":"fig5.png","url":"https://assets-eu.researchsquare.com/files/rs-416046/v1/7a302f99d17c9f2328e0cab3.png"},{"id":9682142,"identity":"eebd6dbe-269e-49b4-a209-9d5ed30cdee4","added_by":"auto","created_at":"2021-05-27 20:25:28","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":209044,"visible":true,"origin":"","legend":"Breast cancer age-adjusted mortality rates per 100,000 for Asian American female decedents, by nativity (US-born vs foreign-born), National Vital Statistics System 2003-2017","description":"","filename":"fig6.png","url":"https://assets-eu.researchsquare.com/files/rs-416046/v1/2bf5d41a47606fe1b08c0ae8.png"},{"id":13695711,"identity":"eca82aa1-fae2-455d-9fba-7f0913c17d8f","added_by":"auto","created_at":"2021-09-17 12:59:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":850185,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-416046/v1/21a00965-2b3d-4444-9f07-345c41634b95.pdf"},{"id":9682094,"identity":"ddbaad9a-4732-47ad-922e-0726181cd419","added_by":"auto","created_at":"2021-05-27 20:19:28","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25064,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigure1.docx","url":"https://assets-eu.researchsquare.com/files/rs-416046/v1/cf5d82952a1f486a774a00db.docx"},{"id":9682098,"identity":"878c328c-9c39-45ac-8253-ff09792cbed0","added_by":"auto","created_at":"2021-05-27 20:19:28","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":18245,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigure2.docx","url":"https://assets-eu.researchsquare.com/files/rs-416046/v1/0224b0edd9fc11f03b85a6c7.docx"},{"id":9682141,"identity":"3b445de8-87a3-44e6-b8f7-b5df3a7ee510","added_by":"auto","created_at":"2021-05-27 20:25:28","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":23165,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigure3.docx","url":"https://assets-eu.researchsquare.com/files/rs-416046/v1/33da25fcb7db4dcbb07929a3.docx"}],"financialInterests":"","formattedTitle":"Female Breast Cancer Trends in Disaggregated Asian American Populations: Analysis of 2003-2017 U.S. Mortality Data","fulltext":[{"header":"Introduction","content":" \u003cp\u003eIn the United States, 1 in 8 women (12%) will be diagnosed with invasive breast cancer in their lifetime and 1 in 39 women (3%) will die due to breast cancer\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Efforts such as emerging treatments and more aggressive screening practices have significantly reduced breast cancer mortality by 40% from 1989 to 2017\u003csup\u003e1\u003c/sup\u003e. Despite this progress, breast cancer is still predicted to be the leading form of new cancer diagnosed in 2020 and will account for 30% of all predicted cancer cases in all American females\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWhen aggregated, women with Asian/Pacific Islander ancestry appear to have the lowest breast cancer incidence (93.7 per 100,000) and death (14 per 100,000) rates of all American racial groups\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e, but the aggregate Asian American (AA) breast cancer incidence has been increasing by 1.5% yearly\u003csup\u003e3,4\u003c/sup\u003e. With over 17.3\u0026nbsp;million AAs in the U.S. in 2010, this rate of increase in breast cancer indicates a significant healthcare burden\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe distinct ethnic subgroups comprising the AA population are extremely diverse in country of origin, length of US residence, acculturation, socioeconomic status, language, culture, religion, and more\u003csup\u003e\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. By aggregating all AAs into a single group, health care providers and policy makers may miss critical heterogeneity around breast cancer healthcare and mortality\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. For example, Thompson et al. examined disaggregated death certificate data of AAs (Asian Indian, Korean, Japanese, Chinese, Vietnamese, and Filipino) from 2003 to 2011 and found that female Filipino Americans had the highest comparative rates of breast cancer amongst the six AA ethnic groups, even if the aggregated AA death rates trended downward\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. However, this study did not find any significant breast cancer mortality trends for any of the AA groups.\u003c/p\u003e \u003cp\u003eIn this study, we present updated trends in female breast cancer mortality rates from 2012 to 2017 among six disaggregated AA ethnicities in comparison with Non-Hispanic White (NHW) females using the Centers for Disease Control and Prevention (CDC) National Vital Statistics System (NVSS) mortality dataset. We also compare current breast cancer mortality trends to previous trends from 2003 to 2011.\u003c/p\u003e "},{"header":"Methods","content":" \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData\u003c/h2\u003e \u003cp\u003eU.S. mortality records between 2003 to 2017 for all fifty states were obtained under an IRB data-use agreement from the CDC NVSS mortality dataset (Protocol # 53429). Death certificates were completed by clinicians and/or medical coroners at time of death and include information about age, sex, race/ethnicity, and cause of death. Underlying causes of death were classified by the International Classification of Diseases (ICD), 10th revision. ICD-10 code C50 (malignant neoplasm of the breast) identified breast cancer as the primary underlying cause of death. Other variables of interest included sex and age.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eFemale NHWs and AAs within six ethnic groups were included: Asian Indians, Chinese, Filipinos, Japanese, Koreans, Vietnamese. Hispanics, African American or Black, Pacific Islanders, and any AAs not in the six selected subgroups were excluded. Males were also excluded from the study. Incomplete death certificates (decedents with missing data for age and primary cause of death variables) and individuals with mixed racial identity or unknown age were excluded. Data analysis was conducted for 473,927 NHW females and 11,388 AA females (1425 Asian Indians, 2898 Chinese, 3865 Filipina, 1549 Japanese, 949 Korean, 702 Vietnamese) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThree different numerical measures were calculated: age-adjusted mortality rates (AAMR), standardized mortality ratios (SMR), and proportionate mortality. AAMR was calculated as the deaths per 100,000 people. Annual percentage change (APC) was calculated as the average percentage change in the fifteen-year period. SMR was calculated as a ratio of the AAMRs with NHW as the reference. Proportionate mortality was calculated as the proportion of breast cancer deaths compared to all cancer deaths. Population counts were extrapolated based on the 2003 and 2010 US Census. To account for the rolling adoption of the 2003 death certificate by state, population adjustment was conducted by enrolling descendants from each state as disaggregated information became available\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Death and population data from each state were included in the numerator and denominator, respectively, when that state adopted the 2003 death certificate. For AAMRs from 2003\u0026ndash;2017, age adjustment was calculated using the 2010 US standard age distribution of the population. The same standard age distribution was applied to each group's age-specific mortality rates in order to compare groups. Nativity population data for each of the six AA subgroups was gathered from the American Community Survey (ACS)\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. We did not suppress data with \u0026lt;\u0026thinsp;10 deaths per cell. A linear model, and not a joinpoint analysis, to analyze the overall trend.\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":" \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eResults for Aggregate AAs\u003c/h2\u003e \u003cp\u003eWe identified 624,221 female AA decedents and 30,269,449 female NHW decedents over the fifteen-year study period, of whom 612,833 female AAs and 30,222,057 female NHWs were excluded and 11,388 female AAs and 473,927 female NHWs died of breast cancer (Supplementary Fig.\u0026nbsp;1). Overall, 13.7% of aggregate female AA and 14.4% female NHW cancer deaths were from breast cancer. AAMRs within disaggregated female AAs ranged from 3.5 per 100,000 (Vietnamese) to 21.6 per 100,000 (Filipina) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Supplementary Fig.\u0026nbsp;2).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eResults for Disaggregated AAs\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eBreast cancer death rates over time\u003c/span\u003e: Temporal AAMR rates demonstrated a significant decrease in NHW breast cancer mortality (APC \u0026minus;\u0026thinsp;2.11; CI -2.63 -1.60; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) while breast cancer mortality in aggregate AAs was AAs was increasing, but not significantly (APC 3.07; CI -0.37 6.50; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Supplementary Fig.\u0026nbsp;2). However, when AAs were disaggregated, Filipinas consistently had the highest AAMR rates, while Japanese women had the lowest rates (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Supplementary Fig.\u0026nbsp;2). In addition, Filipinas had a significantly increasing trend (APC 1.75; CI 0.98 2.53; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as did Chinese (APC 2.00; CI 1.06 2.92; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and Korean (APC 1.98; CI 0.58 3.36, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) women. Japanese women had an insignificant decreasing breast cancer mortality trend (APC \u0026minus;\u0026thinsp;1.88; CI -5.88 2.1, p\u0026thinsp;=\u0026thinsp;0.33). Asian Indians (APC \u0026minus;\u0026thinsp;0.06; CI -2.25 2.37; p\u0026thinsp;=\u0026thinsp;0.96) and Vietnamese women (APC 1.72; CI -0.01 3.45; p\u0026thinsp;=\u0026thinsp;0.05) had stable breast cancer mortality rates with no significant trends.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eProportion of breast cancer deaths\u003c/span\u003e: Although proportionate mortality of breast cancer deaths compared to all cancer deaths for aggregate AAs (13.7%) and NHWs (14.4%) appear comparable, the disaggregated AA ethnicities show great variability (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Asian Indians (19.8%) and Filipinas (18.6%) had the highest proportion of breast cancer deaths, as well as NHWs (14.4%). On the other end, Korean (10.0%), Japanese (10.7%), and Vietnamese women (10.5%) had the lowest proportion of breast cancer mortality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eNativity Analysis\u003c/h2\u003e \u003cp\u003eAn analysis of breast cancer mortality trends from 2003\u0026ndash;2017 for each of the six Asian groups showed no significant differences by place of birth, except for Japanese women (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). US-born Japanese women had decreasing rates of breast cancer deaths (APC \u0026minus;\u0026thinsp;1.0; CI -1.7 -2.4; p 0.0001), while breast cancer deaths increased in foreign-born Japanese (APC 11.4; CI 0.8 6.12; p 0.02) (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e and Supplementary Fig.\u0026nbsp;3).\u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion","content":" \u003cp\u003eOver the past 15 years, we found that non-Hispanic white women have exhibited steadily decreasing breast cancer mortality trends (about 2.1% annually), while the aggregate Asian Americans breast cancer deaths have remained stable. However, when AAs groups are disaggregated, they demonstrate considerable heterogeneity. Specifically, we found that Filipina, Korean and Chinese women have about a 2% annual increase in breast cancer deaths. Moreover, Filipina women had the highest age-adjusted breast cancer rates which were about two times higher than aggregate AAs. By contrast, Vietnamese, Asian Indians, and aggregated AAs exhibited a stable breast cancer mortality trend. While aggregated proportions of cancer deaths were the same for NHW and AA (about 14%), when disaggregated, AA groups demonstrated broad variability in mortality. The large variability in breast cancer mortality rates by AA groups corresponds to results from earlier studies. Thompson et al., found that Filipinas had the highest rate of breast cancer, contributing to 19.5% of all Filipina cancer deaths\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. They also found 19.8% of all Asian Indian cancer deaths were from breast cancer, now the leading cause of all Asian Indian cancer deaths. These findings might be influenced by cancer type, hormone therapy, access to care, screening and lifestyle behaviors amongst women within each AA group.\u003c/p\u003e \u003cp\u003eHigh but stable breast cancer mortality in Asian Indian women and low but stable mortality in Vietnamese women may be influenced by cancer type. Asian Indians are more likely than NHWs to have triple-negative breast cancer\u003csup\u003e\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, which is relatively uncommon and, until recently, without curative targeted therapies\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Conversely, Vietnamese women are more likely to have HER2-positive breast cancer\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, which can have a poor prognosis if not treated optimally with targeted therapies\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. The stable breast cancer mortality among Asian Indian and Vietnamese women may also be influenced by access to care\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Increasing AA breast cancer mortality may be driven by post-menopausal hormone replacement therapy (HRT)\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Breast cancer risk increased 26% per 5 years of current use of estrogen and progestin therapy (p\u0026thinsp;=\u0026thinsp;0.017) in a study of 1,277 Chinese, Japanese, and Filipinas\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Asian and Pacific Islander postmenopausal women may be at higher risk for developing breast cancer (OR 1.58; 95% CI of 1.18\u0026ndash;2.11) than NHW women (OR 1.21; 95% CI 1.14\u0026ndash;1.28) after using HRT\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIncreasing breast cancer mortality in Filipina, Chinese, and Korean women may be due to lack of preventative public health measures, including screening\u003csup\u003e\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e and treatment\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. AA cancer screening rates are lower than those of NHWs for all cancer types\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e and AA women (65%) tend to have lower breast cancer screening rates than NHWs (68%)\u003csup\u003e31\u003c/sup\u003e. In a study comparing mammography rates among AA subgroups, South Asian and Korean women had the lowest mammography rates while Japanese women had the highest rates, second only to NHW women\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. By contrast, Korean American women had the lowest rates of breast cancer screening\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Acculturation, healthcare access, and low levels of health literacy have been posited as potential reasons for reduced breast cancer screening in AAs\u003csup\u003e30,33\u0026minus;35\u003c/sup\u003e. Breast cancer screening rates also vary between the AA subgroups\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLower levels of screening, perhaps coupled with an increase in risk factors associated with a Western lifestyle (e.g., obesity, alcohol, tobacco, unopposed continuous estrogen from reduced and/or delayed parity) may contribute to increasing breast cancer mortality trends within Korean women. In addition, screening behaviors vary by Asian American group. A meta-analysis found that only 34\u0026ndash;65% of Korean women aged 50\u0026ndash;74 reported obtaining a mammogram within the last two years, compared to 73% of white women and 72% of other Asian women\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. Mammography screening among Korean American women in the past two decades has also significantly increased, but these rates are still much lower than NHWs, especially since Korean American women tended to be uninsured and sought out professionals from South Korea where preventative health measures are unusual\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Consistent with their lower utilization of mammography screening, Korean women were twice as likely to be diagnosed with a tumor size\u0026thinsp;\u0026gt;\u0026thinsp;1 cm as compared to White women (OR 2.38; CI 1.49 3.80)\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAmongst Asians, Japanese women had the lowest rates of breast cancer mortality. Not only have Japanese American women been shown to have increased mammography rates compared to other Asians\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e, Japanese American women with breast cancer also had a lower risk of having advanced-stage disease than NHW women or those in other Asian subgroups\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. Increased adoption of breast screening among Japanese may be driven by a larger proportion of acculturated, highly educated, and wealthier Japanese American women as compared by other AA ethnicities\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur study has several limitations. While we captured all deaths in the United States, ethnic/racial groups may have been misclassified unintentionally by the healthcare provider or funeral director completing the death certificate, especially if next-of-kin or family members were not present \u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. However, ethnicity misclassification has been diminishing over time, and are estimated at 3% for Asian Pacific Islanders\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. States\u0026rsquo; adoption of the 2003 death certificate Asian subgroup classification occurred over time, although the states with the largest Asian populations were among the earlier adopters\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Finally, as death certificate data are not linked to other medical information, no information is available about other socioeconomic data that might inform further mortality-related analysis.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eBreast cancer mortality may be improved with healthy lifestyles, early diagnosis via mammographic screening, tailored treatment, and ongoing follow-up. The high and often increasing rates of breast cancer mortality among specific Asian American groups point to the need to disaggregate AA subgroups during research studies, to ensure that potential disparities in access to effective screening, treatment and follow-up care do not go unnoticed and unresolved.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eFunding \u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded and supported by the Stanford Center for Asian Health Research and Education, Palo Alto, CA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConflicts of Interest\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of Data and Material\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCode Availability\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eR Studio, Version 3.6.1\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAmerican Cancer Society. Breast Cancer Facts \u0026amp; Figures 2019-2020. Atlanta: American Cancer Society, Inc. 2019.\u003c/li\u003e\n\u003cli\u003eAmerican Cancer Society. Cancer Facts \u0026amp; Figures 2020. Atlanta: American Cancer Society; 2020.\u003c/li\u003e\n\u003cli\u003eDeSantis CE, Ma J, Gaudet MM, et al. Breast cancer statistics, 2019. CA A Cancer J Clin. 2019;69(6):438-451. doi:10.3322/caac.21583\u003c/li\u003e\n\u003cli\u003eGomez SL, Noone A-M, Lichtensztajn DY, et al. Cancer Incidence Trends Among Asian American Populations in the United States, 1990\u0026ndash;2008. J Natl Cancer Inst. 2013;105(15):1096-1110. doi:10.1093/jnci/djt157\u003c/li\u003e\n\u003cli\u003eHoeffel EM, Rastogi S, Kim MO, Shahid H. The Asian Population: 2010.\u003c/li\u003e\n\u003cli\u003eWu AH, Stram DO, Hamilton AS. Resources and Methods for Studying Cancer Among Asian Americans. In: Cancer Epidemiology Among Asian Americans. Springer International Publishing; 2016. doi:10.1007/978-3-319-41118-7\u003c/li\u003e\n\u003cli\u003eMcCracken M, Olsen M, Chen MS, et al. Cancer Incidence, Mortality, and Associated Risk Factors Among Asian Americans of Chinese, Filipino, Vietnamese, Korean, and Japanese Ethnicities. CA: A Cancer Journal for Clinicians. 2007;57(4):190-205. doi:10.3322/canjclin.57.4.190\u003c/li\u003e\n\u003cli\u003ePew Research Center. The Rise of Asian Americans. Washington, DC: Pew Research Center; 2012.\u003c/li\u003e\n\u003cli\u003eAsian American Center for Advancing Justice. A Community of Contrasts\u0026ndash;Asian Americans in the United States: 2011. Washington, DC: Asian American Center for Advancing Justice; 2011:1\u0026ndash;68.\u003c/li\u003e\n\u003cli\u003eTorre LA, Goding Sauer AM, Chen MS, Kagawa-Singer M, Jemal A, Siegel RL. Cancer Statistics for Asian Americans, Native Hawaiians, and Pacific Islanders, 2015: Convergence of incidence between males and females. CA Cancer J Clin. 2016;66(3):182-202. doi:10.3322/caac.21335\u003c/li\u003e\n\u003cli\u003eSrinivasan S, Guillermo T. Toward improved health: disaggregating Asian American and Native Hawaiian/Pacific Islander data. Am J Public Health. 2000;90(11):1731-1734. doi:10.2105/AJPH.90.11.1731\u003c/li\u003e\n\u003cli\u003eThompson CA, Gomez SL, Hastings KG, et al. The Burden of Cancer in Asian Americans: A Report of National Mortality Trends by Asian Ethnicity. Cancer Epidemiology Biomarkers \u0026amp; Prevention. 2016;25(10):1371-1382. doi:10.1158/1055-9965.EPI-16-0167\u003c/li\u003e\n\u003cli\u003eThompson CA, Boothroyd DB, Hastings KG, Cullen MR, Palaniappan LP, Rehkopf DH. A Multiple-Imputation \u0026ldquo;Forward Bridging\u0026rdquo; Approach to Address Changes in the Classification of Asian Race/Ethnicity on the US Death Certificate. American Journal of Epidemiology. 2018;187(2):347-357. doi:10.1093/aje/kwx215\u003c/li\u003e\n\u003cli\u003eSteven Ruggles, Sarah Flood, Ronald Goeken, Josiah Grover, Erin Meyer, Jose Pacas and Matthew Sobek. IPUMS USA: Version 10.0. Minneapolis, MN: IPUMS, 2020. https://doi.org/10.18128/D010.V10.0\u003c/li\u003e\n\u003cli\u003eKakarala M, Rozek L, Cote M, Liyanage S, Brenner DE. Breast cancer histology and receptor status characterization in Asian Indian and Pakistani women in the U.S. - a SEER analysis. BMC Cancer. 2010;10(1):191. doi:10.1186/1471-2407-10-191\u003c/li\u003e\n\u003cli\u003eParise C, Caggiano V. Disparities in the risk of the ER/PR/HER2 breast cancer subtypes among Asian Americans in California. Cancer Epidemiology. 2014;38(5):556-562. doi:10.1016/j.canep.2014.08.001\u003c/li\u003e\n\u003cli\u003eDenkert C, Liedtke C, Tutt A, Von Minckwitz G. Molecular alterations in triple-negative breast cancer\u0026mdash;the road to new treatment strategies. The Lancet. 2017;389(10087):2430-2442. doi:10.1016/S0140-6736(16)32454-0\u003c/li\u003e\n\u003cli\u003eMcCann KE, Hurvitz SA, McAndrew N. Advances in Targeted Therapies for Triple-Negative Breast Cancer. Drugs. 2019;79(11):1217-1230. doi:10.1007/s40265-019-01155-4\u003c/li\u003e\n\u003cli\u003eTelli ML, Chang ET, Kurian AW, et al. Asian ethnicity and breast cancer subtypes: a study from the California Cancer Registry. Breast Cancer Res Treat. 2011;127(2):471-478. doi:10.1007/s10549-010-1173-8\u003c/li\u003e\n\u003cli\u003eArteaga CL, Sliwkowski MX, Osborne CK, Perez EA, Puglisi F, Gianni L. Treatment of HER2-positive breast cancer: current status and future perspectives. Nature Reviews Clinical Oncology. 2012;9(1):16-32. doi:10.1038/nrclinonc.2011.177\u003c/li\u003e\n\u003cli\u003eLoibl S, Gianni L. HER2-positive breast cancer. The Lancet. 2017;389(10087):2415-2429. doi:10.1016/S0140-6736(16)32417-5\u003c/li\u003e\n\u003cli\u003eGradishar WJ, Anderson BO, Abraham J, et al. Breast Cancer, Version 3.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2020;18(4):452-478. doi:10.6004/jnccn.2020.0016\u003c/li\u003e\n\u003cli\u003eCoombs NJ, Cronin KA, Taylor RJ, Freedman AN, Boyages J. The impact of changes in hormone therapy on breast cancer incidence in the US population. Cancer Causes Control. 2010;21(1):83-90. doi:10.1007/s10552-009-9437-5\u003c/li\u003e\n\u003cli\u003eWu AH, Yu MC, Tseng C-C, Pike MC. Body size, hormone therapy and risk of breast cancer in Asian\u0026ndash;American women. International Journal of Cancer. 2007;120(4):844-852. doi:https://doi.org/10.1002/ijc.22387\u003c/li\u003e\n\u003cli\u003eHou N, Hong S, Wang W, Olopade OI, Dignam JJ, Huo D. Hormone replacement therapy and breast cancer: heterogeneous risks by race, weight, and breast density. J Natl Cancer Inst. 2013;105(18):1365-1372. doi:10.1093/jnci/djt207\u003c/li\u003e\n\u003cli\u003eOh KM, Taylor KL, Jacobsen KH. Breast Cancer Screening Among Korean Americans: A Systematic Review. J Community Health. 2017;42(2):324-332. doi:10.1007/s10900-016-0258-7\u003c/li\u003e\n\u003cli\u003eSadler GR, Wang K, Wang M, Ko CM. Chinese women: behaviors and attitudes toward breast cancer education and screening. Women\u0026rsquo;s Health Issues. 2000;10(1):20-26. doi:10.1016/S1049-3867(99)00046-8\u003c/li\u003e\n\u003cli\u003eKo CM, Sadler GR, Ryujin L, Dong A. Filipina American women\u0026rsquo;s breast cancer knowledge, attitudes, and screening behaviors. BMC Public Health. 2003;3(1):27. doi:10.1186/1471-2458-3-27\u003c/li\u003e\n\u003cli\u003eGelber RP, McCarthy EP, Davis JW, Seto TB. Ethnic Disparities in Breast Cancer Management Among Asian Americans and Pacific Islanders. Ann Surg Oncol. 2006;13(7):977-984. doi:10.1245/ASO.2006.08.036\u003c/li\u003e\n\u003cli\u003eShi L, Lebrun LA, Zhu J, Tsai J. Cancer screening among racial/ethnic and insurance groups in the United States: a comparison of disparities in 2000 and 2008. J Health Care Poor Underserved. 2011;22(3):945-961. doi:10.1353/hpu.2011.0079\u003c/li\u003e\n\u003cli\u003eRyu SY, Crespi CM, Maxwell AE. What Factors Explain Disparities in Mammography Rates Among Asian-American Immigrant Women? A Population-Based Study in California. Women\u0026rsquo;s Health Issues. 2013;23(6):e403-e410. doi:10.1016/j.whi.2013.08.005\u003c/li\u003e\n\u003cli\u003eSentell T, Braun KL, Davis J, Davis T. Health literacy and meeting breast and cervical cancer screening guidelines among Asians and whites in California. Springerplus. 2015;4:432. doi:10.1186/s40064-015-1225-y\u003c/li\u003e\n\u003cli\u003eKandula NR, Wen M, Jacobs EA, Lauderdale DS. Low rates of colorectal, cervical, and breast cancer screening in Asian Americans compared with non-Hispanic whites. Cancer. 2006;107(1):184-192. doi:10.1002/cncr.21968\u003c/li\u003e\n\u003cli\u003eLee S, Chen L, Jung MY, Baezconde-Garbanati L, Juon H-S. Acculturation and Cancer Screening Among Asian Americans: Role of Health Insurance and Having a Regular Physician. J Community Health. 2014;39(2):201-212. doi:10.1007/s10900-013-9763-0\u003c/li\u003e\n\u003cli\u003eLee HY, Ju E, Vang PD, Lundquist M. Breast and Cervical Cancer Screening Disparity Among Asian American Women: Does Race/Ethnicity Matter? Journal of Women\u0026rsquo;s Health. 2010;19(10):1877-1884. doi:10.1089/jwh.2009.1783\u003c/li\u003e\n\u003cli\u003eHedeen AN, White E, Taylor V. Ethnicity and birthplace in relation to tumor size and stage in Asian American women with breast cancer. Am J Public Health. 1999;89(8):1248-1252. doi:10.2105/AJPH.89.8.1248\u003c/li\u003e\n\u003cli\u003eMcPherson K, Steel CM, Dixon JM. Breast cancer\u0026mdash;epidemiology, risk factors, and genetics. BMJ. 2000;321(7261):624-628.\u003c/li\u003e\n\u003cli\u003eLiu L, Zhang J, Wu AH, Pike MC, Deapen D. Invasive breast cancer incidence trends by detailed race/ethnicity and age. \u003cem\u003eInt J Cancer\u003c/em\u003e. Published online 2012:10.\u003c/li\u003e\n\u003cli\u003eHou N, Hong S, Wang W, Olopade OI, Dignam JJ, Huo D. Hormone replacement therapy and breast cancer: heterogeneous risks by race, weight, and breast density. J Natl Cancer Inst. 2013;105(18):1365-1372. doi:10.1093/jnci/djt207\u003c/li\u003e\n\u003cli\u003eAccess Versus Acculturation: Identifying Modifiable Factors to Promote Cancer Screening Among Asian American Women. Published online 2021:10.\u003c/li\u003e\n\u003cli\u003eThe Validity of Race and Hispanic-Origin Reporting on Death Certificates in the United States: An Update. Centers for Disease Control and Prevention; 2016:29.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cancer-causes-and-control","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"caco","sideBox":"Learn more about [Cancer Causes \u0026 Control](https://www.springer.com/journal/10552)","snPcode":"10552","submissionUrl":"https://submission.nature.com/new-submission/10552/3","title":"Cancer Causes \u0026 Control","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Breast cancer, Non-Hispanic White (NHW), Age-adjusted mortality rates (AAMR), proportional mortality rates (PMR).","lastPublishedDoi":"10.21203/rs.3.rs-416046/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-416046/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose\u003c/p\u003e\u003cp\u003eBreast cancer is the second leading cause of female cancer mortality in the United States and breast cancer mortality in Asian Americans (AA) is rising by 1.5% per year. However, aggregated AA breast cancer death rates may mask important mortality differences in major AA groups.\u003c/p\u003e\u003cp\u003ePopulation \u0026amp; Setting\u003c/p\u003e\u003cp\u003e11,388 AA and 473,927 non-Hispanic White (NHW) females based on the United States Centers for Disease Control and Prevention National Vital Statistics System database 2003-2017.\u003c/p\u003e\u003cp\u003eMethods\u003c/p\u003e\u003cp\u003eAge-adjusted mortality rates (AAMR) were used to estimate trends in breast cancer mortality in Asian Indians, Chinese, Filipinas, Japanese, Koreans, Vietnamese, and non-Hispanic Whites from 2003–2017, with attention to annual percentage change (APC) and proportional mortality rates (PMR).\u003c/p\u003e\u003cp\u003eResults\u003c/p\u003e\u003cp\u003eFrom 2003-2017, breast cancer deaths comprised 14.4% in NHWs, 13.7% in aggregate AAs, 19.8% in Asian Indians, and 18.6% of all cancer deaths in Filipinas. While NHW breast cancer mortality rate significantly decreased (APC -2.1; CI -2.6, -1.6; p \u0026lt; 0.001) from 2003 to 2017, aggregate AA mortality rates were unchanged (APC 3.07; CI -0.37, 7.8; p = 0.071). However, when disaggregated, breast cancer mortality in Filipina (APC 1.9; CI 0.8, 3.0; p \u0026lt; 0.002), Chinese (APC 2.1; CI 1.3, 3.0; p \u0026lt; 0.001), and Korean (APC 2.6; CI 1.0, 4.1; p = 0.004) women significantly increased. Breast cancer mortality rates in Japanese women decreased (APC -1.9; CI -5.9, 2.1; p = 0.3).\u003c/p\u003e\u003cp\u003eConclusion\u003c/p\u003e\u003cp\u003eWhile the proportion of women dying from breast cancer were similar in NHWs and aggregate Asians, when disaggregated, Filipina, Korean, and Chinese women had increased mortality rates over the past 15 years. During this time, breast cancer mortality in NHW and Japanese women decreased. Understanding disaggregated breast cancer mortality rates in Asians may improve culturally-tailored outreach, prevention, and treatment strategies to reduce cancer deaths from this critical disease.\u003c/p\u003e","manuscriptTitle":"Female Breast Cancer Trends in Disaggregated Asian American Populations: Analysis of 2003-2017 U.S. Mortality Data","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-05-27 20:19:26","doi":"10.21203/rs.3.rs-416046/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revisions","date":"2021-07-01T09:20:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-06-10T00:00:00+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-05-24T08:49:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-04-13T00:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"Cancer Causes \u0026 Control","date":"2021-04-11T18:11:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cancer-causes-and-control","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"caco","sideBox":"Learn more about [Cancer Causes \u0026 Control](https://www.springer.com/journal/10552)","snPcode":"10552","submissionUrl":"https://submission.nature.com/new-submission/10552/3","title":"Cancer Causes \u0026 Control","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f3205d75-04e9-4dc4-9510-5f514b5bb434","owner":[],"postedDate":"May 27th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[{"id":4616980,"name":"Oncology"}],"tags":[],"updatedAt":"2022-06-27T11:56:47+00:00","versionOfRecord":[],"versionCreatedAt":"2021-05-27 20:19:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-416046","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-416046","identity":"rs-416046","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}