Measuring risk factors and incidence of cardiotoxicity and integrative therapy utilization in South Asian women with breast cancer: A single institution experience.
Authors: Patel Rushil Virendra , Patrick Alicia L. , Zeng Hang , Symanowski James Thomas , Bailey-Dorton Chasse Margot , Prabhu Roshan Sudhir , Tan Antoinette R. , Heeke Arielle Lutterman 
Published: September 2022

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Background: Cancer survivors are at risk for cardiac dysfunction, and ASCO guidelines recommend identifying at-risk individuals prior to treatment. South Asian women (SAW) have an elevated risk of cardiovascular disease (CVD) based on their ethnicity. Management of SAW with breast cancer could be improved by understanding their use of culturally-relevant integrative therapies (IT). This study measures CVD risk factors at baseline, CVD events following treatment, and IT utilization in SAW with breast cancer. Methods: Asian Indian (AI), Pakistani (P), or Nepalese (N) women (age ≥18 years) with histologically confirmed, newly diagnosed breast cancer who received cancer-directed therapy between February 2008 and June 2021 were identified. A cohort of non-SAW was matched based on age, year, and stage at diagnosis. Clinical and treatment characteristics, CVD risk factors, and event data were collected. Based on 2017 ASCO guidelines & 2021 American College of Cardiology updates, at-risk for cardiotoxicity was defined by the receipt of anthracycline or anti-HER2 therapy and ≥1 risk factor: age ≥60 years, ejection fraction ≤55%, history of myocardial infarction, moderate valvular disease, congestive heart failure, or ≥2 lifestyle risk factors during or after treatment (tobacco use, hypertension, diabetes, dyslipidemia, obesity [race/ethnicity specific BMI: ≥30 White; ≥28.1 Black; ≥23.9 South Asian]). McNemars test for paired nominal observations was performed to assess differences between cohorts (p < 0.05). Univariable logistic regression analyses were performed to identify associations between CVD risk and IT use (p < 0.05). Results: Of 29,610 breast cancer patients with race/ethnicity data available, 33 (0.11%) were SAW (91% AI, 6% P, 3% N). Median age was 54 years and 42% had Stage 2 disease. Median follow-up was 50 months. SAW had a lower median BMI (24 vs 31 kg/m2; p = 0.004) and less tobacco (0% vs 12%) and alcohol use (13% vs 33%). At baseline, less SAW had ≥1 CVD risk factor (70% vs. 82%; p = 0.157). SAW had lower incidence of hypertension (42% vs 67%; p = 0.005) and higher incidence of diabetes (30% vs 6%; p = 0.011). Both cohorts were equally at-risk for cardiac dysfunction (18%), which was not associated with radiation therapy (p = 0.672) or post-menopausal status (p = 0.209). SAW had a higher number of subsequent CVD events (5 vs 1; p = 0.313). More SAW used IT (36% vs 24%; p = 0.206) and SAW exclusively used Ayurveda (12%) and yoga (9%). Being at-risk for cardiotoxicity was not associated with IT use (p = 0.801). Conclusions: While SAW had a higher incidence of CVD events following treatment, this did not reach significance. Risk may be driven by a higher incidence of diabetes. Larger studies with longer follow-up are needed to inform guidelines. Future interventions to modify risk should incorporate culturally-relevant IT, like Ayurveda and yoga.