Inequity in care delivery in cardio-oncology: dissecting disparities in underrepresented populations

County-Level Urbanization and Cardiovascular Death in Patients With Cancer

CONTEXT

Cardiovascular death (CVD) is a leading cause of mortality in patients with cancer, with sociodemographic factors such as urbanization influencing outcomes.

OBJECTIVE

To examine the impact of county-level urbanization on CVD mortality in patients with cancer in the United States from 1999 to 2020.

DESIGN

Retrospective cross-sectional analysis using CDC WONDER mortality data.

SETTING

US counties categorized as rural or urban based on the 2013 NCHS Urban-Rural Classification Scheme.

PARTICIPANTS

Patients with cardiovascular disease (ICD-10: I00-I78) and comorbid cancer (ICD-10: C00-C97), spanning all U.S. counties from 1999 to 2020.

MAIN OUTCOME MEASURES

Age-adjusted mortality rates (AAMRs) per 100 000 population and rural-to-urban rate ratios (RRs) with 95% confidence intervals.

RESULTS

The cumulative rural-to-urban RR for CVD in patients with cancer was 1.11 (95% CI: 1.10-1.11), increasing from 1.00 in 1999 to 1.20 in 2020 (β = 0.009, P < .001). Rural AAMRs were higher across demographic groups, including males (12.85 vs 11.62 per 100 000), females (6.08 vs 5.58), Black individuals (9.76 vs 9.64), and White individuals (8.79 vs 7.94). Rural Black populations showed a rising RR from 0.85 in 1999 to 1.04 in 2020 (β = 0.005, P = .01). Hispanic populations exhibited lower rural mortality, with a stable RR (0.93, P = 1.0). The most common CVD cause was ischemic heart disease (53.93% of rural and 55.9% of urban deaths).

CONCLUSIONS

An increasing rural-to-urban disparity in CVD mortality among cancer patients highlights the role of urbanization in health inequities. Interventions targeting rural health care access and socioeconomic disparities are essential to address this growing gap.

Racial and Ethnic Disparities in Cardio-Oncology Care

PURPOSE OF REVIEW

This review examines racial, ethnic, and socioeconomic disparities in cardio-oncology care, evaluating current evidence and proposing evidence-based strategies to address inequities in cardiovascular care for cancer patients.

RECENT FINDINGS

Significant disparities exist in cardio-oncology outcomes and access across populations. Racial and ethnic minoritized groups face higher cardiovascular mortality and increased cardiotoxicity risks during cancer treatment. These populations also preset with more advanced-stage cancer diagnoses and increased burden of cardiovascular risk factors. Social vulnerability indices strongly correlate with worse outcomes, while geographic location and environmental factors create additional risks. Rural populations particularly struggle with access to specialized care and clinical trials. Multiple factors contribute to disparities in cardio-oncology, including social determinants of health, disproportionate burden of cardiovascular risk factors, barriers to access, and environmental exposures. Key solutions include expanding access to subspecialty care, creation of collaborations between academic centers and community hospitals, particularly those in underserved communities, enhancing community engagement and public health education, improving clinical trial representation, increasing workforce diversity, and enhancing cultural competency. These findings emphasize the need for systematic healthcare delivery changes and resource allocation to achieve equitable cardio-oncology care for all populations.

Assessment and stratification of cardiovascular disease risk in people diagnosed with breast cancer: A scoping review

BACKGROUND

Breast cancer patients are at increased risk of cardiovascular disease, which often are associated with cardiotoxic breast cancer treatment or overlapping risk factors between the two diseases. Pre-treatment cardiovascular risk assessment can enable accurate risk stratification and prevention of cardiovascular disease. Several tools have been suggested, described or used in research to assess baseline (pre-treatment) risk to determine appropriate cardiovascular disease care before, during and after cancer treatment. This scoping review aims to identify and describe key features of baseline cardiovascular disease risk assessment tools for breast cancer patients.

METHODS

PubMed, Embase and Google Scholar were searched for articles published January 2013 - March 2024 to identify publications reporting cardiovascular disease risk assessment tools in breast cancer patients. Publications included research articles (observational and experimental studies) and position/policy, commentary and review papers. Eligibility was assessed and key data were extracted independently by two reviewers. Conflicts were discussed and resolved with the authorship team.

RESULTS

A total 144 articles were identified. Of these, 57 reported original data for the development, validation or recommendations of cardiovascular disease risk assessment tools and 87 reported the use of such tools. From these articles, 13 tools were identified that assessed the risk of cardiovascular disease broadly (n = 3) or death due to cardiovascular disease (n = 1) or specifically of cardiotoxicity or heart failure (n = 8) or venous thromboembolism (n = 1) in people diagnosed with breast cancer. Fourteen tools assessed cardiovascular disease risk in people diagnosed with mixed cancer types, including breast cancer. The planned development of four tools and/or surveillance pathways were described in protocol papers. Among all these tools identified (n = 31), seven tools (among these, four tools assessed people diagnosed with breast cancer only) went through external validation and performed poorly or moderately in stratifying cancer patients effectively into risk categories. Risk factors included in the assessment tools were age, breast cancer treatment type and pre-existing cardiovascular disease. While clinical guidelines and recommendations about baseline cardiovascular disease risk assessment were identified, these were either for cancer patients broadly or for cancer treatment types, and not specifically for people diagnosed with breast cancer.

CONCLUSION

Several tools to assess baseline cardiovascular disease in people diagnosed with breast cancer were identified but only seven tools had gone through a validation process, and none were found to be very effective in differentiating people by baseline cardiovascular disease risk. Further work is needed to optimise the effectiveness of baseline cardiovascular disease risk assessments for breast cancer patients to enable appropriate stratification and monitoring of risk before, during and after treatment to improve cardiovascular health and outcomes.

Investigating modifiable risk factors associated with ideal cardiovascular health among cancer survivors: a scoping review

BACKGROUND

Cancer survivors are at higher risk of developing cardiovascular diseases and face worse morbidity and mortality outcomes than the general population. The American Heart Association (AHA) introduced the Life's Essential 8 framework, encompassing eight modifiable risk factors and lifestyle behaviors for maintaining ideal cardiovascular health (CVH). Although this framework is well-established for predicting CVH in the general population, studies on its association with cardiovascular outcomes among cancer survivors remain scattered across the literature.

OBJECTIVE

This review maps existing literature surrounding modifiable risk factors, lifestyle behaviors, CVH, and cardiovascular outcomes among cancer survivors to take stock of what is known, identify methodological strengths and weaknesses, and propose promising research directions.

METHODS

A scoping review was conducted to identify studies examining different dimensions of ideal CVH in adult cancer survivors. Measurement methods of ideal CVH metrics, and determinants associated with CVH were examined.

RESULTS

Twenty-two articles met eligibility criteria. Of which, 82% (n = 18) were published in or after 2020. Fourteen studies (about 64%) followed the AHA's framework to conceptualize ideal CVH. Higher scores on ideal CVH are linked to better cardiovascular outcomes among cancer survivors with associations noted for social inequalities and neighborhood environmental factors, underscoring the complexity of CVH determinants in this population.

CONCLUSIONS

Research on ideal CVH among cancer survivors appears to have accelerated in recent years, yet many gaps remain to orient clinical and public health practice. Promising research directions include expanding investigations into pre-diagnosis CVH, addressing disparities in CVH across diverse populations, and conducting longitudinal studies to clarify causal pathways between lifestyle behaviors, cancer treatments, and cardiovascular outcomes.

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.

Navigating the crossroads: cardiometabolic risks in cancer survivorship - a comprehensive review

The landscape of cancer survivorship is increasingly populated by individuals facing a spectrum of cardiometabolic risks, attributed to both their oncological history and treatment regimens. This manuscript synthesizes findings from various studies, highlighting the prevalence of traditional risk factors-hypertension, dyslipidemia, diabetes-as well as emergent concerns like obesity and metabolic syndrome among survivors. The impact of demographic variables, specific cancer types, and treatment modalities on cardiometabolic health is explored. Through a lens of multidisciplinary management and future research directives, we advocate for an integrative approach to cardiometabolic health in cancer survivors, aiming to ensure their victory over cancer extends into long-term well-being. Furthermore, we discuss the outcome implications of these cardiometabolic risk factors on cardiovascular disease development, future cardiovascular events, and overall survival, supported by studies showing improved outcomes through exercise and risk factor control.

Navigating the crossroads: cardiometabolic risks in cancer survivorship - a comprehensive review

The landscape of cancer survivorship is increasingly populated by individuals facing a spectrum of cardiometabolic risks, attributed to both their oncological history and treatment regimens. This manuscript synthesizes findings from various studies, highlighting the prevalence of traditional risk factors-hypertension, dyslipidemia, diabetes-as well as emergent concerns like obesity and metabolic syndrome among survivors. The impact of demographic variables, specific cancer types, and treatment modalities on cardiometabolic health is explored. Through a lens of multidisciplinary management and future research directives, we advocate for an integrative approach to cardiometabolic health in cancer survivors, aiming to ensure their victory over cancer extends into long-term well-being.

Socioeconomic and Ethnic Disparities in the Process of Care and Outcomes Among Cancer Patients With Acute Coronary Syndrome

Cancer and acute coronary syndrome (ACS) are the leading causes of morbidity and mortality globally, with many shared risk factors. There are several challenges to the management of patients with cancer presenting with ACS, owing to their higher baseline risk profile, the complexities of their cancer-related therapies and prognosis, and their higher risk of adverse outcomes after ACS. Although previous studies have demonstrated disparities in the care of both cancer and ACS among patients from ethnic minorities and socioeconomic deprivation, there is limited evidence around the magnitude of such disparities specifically in cancer patients presenting with ACS. This review summarises the current literature on differences in prevalence and management of ACS among patients with cancer from ethnic minorities and socioeconomically deprived backgrounds, as well as the gaps in evidence around the care of this high-risk population and potential solutions.

Social Determinants of Health in Cardio-Oncology: Multi-Level Strategies to Overcome Disparities in Care: JACC: CardioOncology State-of-the-Art Review

Addressing the need for more equitable cardio-oncology care requires attention to existing disparities in cardio-oncologic disease prevention and outcomes. This is particularly important among those affected by adverse social determinants of health (SDOH). The intricate relationship of SDOH, cancer diagnosis, and outcomes from cardiotoxicities associated with oncologic therapies is influenced by sociopolitical, economic, and cultural factors. Furthermore, mechanisms in cell signaling and epigenetic effects on gene expression link adverse SDOH to cancer and the CVD-related complications of oncologic therapies. To mitigate these disparities, a multifaceted strategy is needed that includes attention to health care access, policy, and community engagement for improved disease screening and management. Interdisciplinary teams must also promote cultural humility and competency and leverage new health technology to foster collaboration in addressing the impact of adverse SDOH in cardio-oncologic outcomes.

Integrating Cardio-Oncology Across the Research Pipeline, Policy, and Practice in Australia-An Australian Cardiovascular Alliance Perspective

Over 18 million people worldwide were diagnosed with cancer in 2020, including over 150,000 people in Australia. Although improved early detection and treatment have increased the survival rates, cardiotoxic treatment and inadequate management of cardiovascular risk factors have resulted in cardiovascular disease (CVD) being one of the leading causes of non-cancer-related death and disability among cancer survivors. International guidelines outline the standards of care for CVD risk surveillance and management. However, Australian cardio-oncology policies and clinical guidelines are limited. There is increasing growth of cardio-oncology research in Australia and support from leading Australian professional bodies and advocacy and research networks, including the Cardiac Society of Australia and New Zealand, the Clinical Oncology Society of Australia, the National Heart Foundation of Australia, and the Australian Cardiovascular Alliance (ACvA). Thus, opportunities to drive multidisciplinary cardio-oncology initiatives are growing, including grant funding, position statements, and novel research to inform new policies. The ACvA has a unique flagship structure that spans the translational research pipeline from drug discovery to implementation science. This article aims to highlight how multidisciplinary cardio-oncology innovations could intersect with the seven ACvA flagships, and to showcase Australian achievements in cardio-oncology thus far. We summarise eight key priority areas for future cardio-oncology research that emerged. These strategies will strengthen cardio-oncology research and care in Australia, and drive new guidelines, policies, and government initiatives to ensure equity in health outcomes for all cardio-oncology patients.

Cancer and cardiotoxicity in the transgender population

The relationship between cancer diagnosis and cardiovascular diseases is complex, with newly diagnosed patients facing a higher risk of coronary disease, heart failure, and atrial fibrillation. Compared to the general population, they have two to six times more risk of dying from cardiovascular causes. Cardiovascular complications arising from chemotherapy and radiotherapy, along with social and healthcare access disparities, complicate the collection of accurate data on the incidence of cancer and cardiotoxicity in marginalized populations. Among the LGBTQ community, certain types of cancer are more prevalent, and hormone administration for gender affirmation is also under study. The delay in cancer screening in the transgender population results in late detections and deaths from cancer. Research on cancer in the transgender population and cardiotoxicity is limited, but special attention is needed to develop detection and prevention strategies in specific situations, such as hormone-dependent tumors.