Black cancer survivors in the United States may experience a higher incidence of cardiovascular disease and associated mortality than White cancer survivors, according to a recent study published by Sung et al in the International Journal of Epidemiology. The investigators also found that differences in neighborhood socioeconomic status and health insurance between White and Black cancer survivors might explain the disparities in cardiovascular mortality.
“The findings have implications for clinical guidelines for evaluating cardiovascular risk and prognosis among [patients] with a history of cancer,” explained lead study author Hyuna Sung, PhD, a senior principal scientist in the Department of Cancer Surveillance Research at the American Cancer Society (ACS). “Although it is well established that incorporating social determinants of health screenings and interventions into cardiovascular care significantly improves patient outcomes, current guidelines concerning cardiovascular health and risk management among cancer survivors mostly omit social determinants of health–informed approaches. These guidelines can be updated to incorporate [these] practices and to help providers identify and address their patient’s social needs,” she added.
Study Methods and Results
In the new study, the investigators used 17 Surveillance, Epidemiology, and End Results registries to examine the population-based data of over 900,000 U.S. cancer survivors aged 20 to 64 years. They sought to better understand the impact of census tract–level neighborhood socioeconomic factors such as education level, percent working class, percent unemployment, median household income, median house value, median rent, and poverty level—in addition to clinical factors—on differences in mortality.
After a median follow-up of 43 months, the investigators found that 10,701 cancer survivors died from cardiovascular disease. Black cancer survivors had up to a threefold higher risk of mortality from cardiovascular disease than White cancer survivors, with hazard ratios ranging across 18 cancer types. For instance, Black cancer survivors were more likely to die from cardiovascular disease if they had a history of lung cancer (hazard ratio [HR] = 1.30, 95% confidence interval [CI] = 1.15–1.47) and if they had a history of brain cancer (HR = 4.04, 95% CI = 2.79–5.83).
Further, results based on mediation analyses suggested that 25% to 64% of the excess cardiovascular disease mortality among Black cancer survivors of 14 cancer types may be accounted for by racial differences in neighborhood socioeconomic status. Approximately 64% of the excess cardiovascular disease mortality among Black lung cancer survivors vs White lung cancer survivors was mediated by socioeconomic disparities in neighborhoods where Black cancer survivors and White cancer survivors resided. Racial disparities in health insurance status also appeared to be significant contributing factors and may explain the 12% to 31% higher mortality rates among Black cancer survivors.
Conclusions
While the study may have identified a link between neighborhood-level socioeconomic status and cardiovascular disease mortality after a cancer diagnosis, it was not designed to determine which specific attributes captured with the neighborhood measure were most influential.
“Where you live shouldn’t determine if you live, but unfortunately, that’s the reality for far too many [patients],” stressed Lisa A. Lacasse, MBA, President of the ACS Cancer Action Network. “Successfully fighting cancer depends on access to timely, high-quality, affordable health-care coverage and treatment. This study underscores the importance of ensuring that everyone has equitable access to high-quality affordable health care, which includes expanding Medicaid in the 10 remaining states that have not done so. This would cover more than 2 million uninsured [patients] who fall into a Medicaid coverage gap—nearly 30% of whom are Black.”
“These findings underscore the importance of neighborhood-level interventions and equitable access to care to mitigate the racial inequities in [cardiovascular disease] mortality among cancer survivors,” emphasized Dr. Sung. “We need to identify and support neighborhoods where targeted efforts for health promotion and cancer survivorship can have the greatest impact,” she concluded.
Disclosure: For full disclosures of the study authors, visit academic.oup.com.
