Date of Award

January 2022

Document Type


Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Melinda Irwin


Background: Known racial/ethnic disparities in cardiovascular disease (CVD) mortality among breast cancer survivors exist and it is well-documented that non-Hispanic Black (NHB) breast cancer survivors experience higher incidence of CVD mortality compared to NHW women. However, few studies have examined CVD mortality among Asian American, Native Hawaiian, and other Pacific Islanders (AANHPI) survivors, especially with respect to socioeconomic factors and rurality at the county-level. The aim of this study was to describe how county-level factors influence disparities in CVD mortality among AANHPI breast cancer survivors. Methods: Using Surveillance, Epidemiology, and End Results 18 registries, we analyzed a retrospective cohort of 60,184 AANHPI women diagnosed with first primary, invasive breast cancer at ages 18-84 years between 2000-2017 who survived at least one year. We used Poisson regression models to calculate relative risks (RR) of CVD mortality, accounting for rates in the general population of AANHPI, according to county-level tertiles of SES (measured by the Yost Index), median income, and degree of rurality. We then assessed for trends in county-level SES and tested for heterogeneity by rurality. We additionally calculated 10-year cumulative CVD mortality estimates accounting for competing risks (non-CVD deaths). Results: After adjusting for breast cancer stage, age, and year at diagnosis, AANHPI breast cancer survivors living in counties of the lowest SES had a 22% higher risk of CVD mortality (RR = 1.22; 95% CI [1.05, 1.41], p-trend <0.001) compared to those living in counties of the highest SES, a 12% higher risk (RR = 1.12; 95% CI [0.99,1.28], p-trend 0.080) for those living in the poorest relative to wealthiest counties, and 56% higher risk (RR = 1.56; 95% CI [1.25, 1.95], p-heterogeneity <0.001) for those living in the most rural relative to most urban counties. The poorest counties had a 10-year cumulative CVD mortality of 2.33% (95% CI 2.04%,2.65%) compared to the wealthiest counties of 2.19% (95% CI 1.99%, 2.40%). Estimates were amplified by rurality where the most rural counties had a 10-year cumulative CVD mortality of 4.38% (95% CI 3.34%, 5.64%) compared to the most urban counties at 1.84% (95% CI 1.68%, 2.01%). Conclusion: County-level SES factors and rurality affect AANHPI breast cancer survivors’ CVD mortality risk.


This thesis is restricted to Yale network users only. It will be made publicly available on 05/19/2023