Based on the results of a retrospective cohort study published by Demissei et al in JACC: CardioOncology, Black patients with prostate cancer who received systemic androgen-deprivation therapy (ADT) seemed to have a significantly greater likelihood of experiencing adverse cardiovascular disease outcomes than their White counterparts. The researchers noted that socioeconomic status and other structural determinants of health largely mediated this racial disparity.
“Our work identifies an urgent, unmet need for greater attention to cardiovascular disease management in men with prostate cancer,” the investigators remarked. “As the most common cancer in men in the United States, this represents a critically important public health priority.”
Study Details
A total of 3,543 patients with prostate cancer (median age = 70 years) who received gonadotropin-releasing hormone (GnRH) agonist– or GnRH antagonist–based systemic ADT at the University of Pennsylvania Health System between 2008 and 2021 were included in the analysis. Of this population, 1,079 (30.4%) were Black, 2,227 (62.9%) were White, 63 (1.8%) were Asian, and 96 (2.7%) self-identified as other race.
Major adverse cardiovascular events were defined as heart failure, coronary heart disease, cerebrovascular disease, peripheral artery disease, ventricular tachycardia/fibrillation, and cardiovascular mortality. Using cause-specific proportional hazards, the investigators evaluated the multivariable adjusted association between self-reported race (Black vs White) and incident major adverse cardiovascular events after the initiation of ADT.
The investigators conducted a mediation analysis to determine the role of structural social determinants of health (as defined by the Centers for Disease Control and Prevention social vulnerability index [SVI]) in explaining the racial disparities in cardiovascular disease outcomes. Calculations were based on the relative rankings of census tracts in the United States across four themes: socioeconomic status; household composition and disability; minority status and language; and housing type and transportation.
KEY POINTS
- Preexisting cardiovascular risk factors and disease were more frequently documented in Black vs White patients with prostate cancer.
- Although the adjusted analyses revealed no differences in prostate cancer mortality, Black patients who received ADT were found to have a 1.38-fold greater hazard of incident major adverse cardiovascular events than their White counterparts.
- The racial disparities in cardiovascular outcomes seemed to be mediated by socioeconomic status and other structural determinants of health.
Disparities in Preexisting Cardiovascular Risk Factors and Disease
The prevalence of preexisting cardiovascular risk factors, such as smoking (60.4% vs 47.1%; P < .001), hypertension (79.3% vs 69.4%; P < .001), and diabetes (33.6% vs 17.9%; P < .001), was reportedly greater in Black vs White patients at the initiation of ADT. Similarly, regarding cardiovascular disease, the rates of heart failure (10.2% vs 5.0%; P < .001) and cerebrovascular disease (10.8% vs 7.9%; P = .006) were found to be higher in the former racial subgroup. White patients exhibited higher rates of hyperlipidemia (56.2% vs 64.6%; P < .001) and coronary heart disease (14.6% vs 20.4%; P < .001) than Black patients.
Disparities in Incident Cardiovascular Outcomes
Although the analyses that adjusted for age and cancer stage revealed no significant differences in prostate cancer mortality (hazard ratio [HR] = 1.13; P = .27), Black patients were found to have a 38% greater hazard of incident major adverse cardiovascular events than White patients (HR = 1.38; P < .001). According to the investigators, the association was strongest for incident heart failure (HR = 1.79; P < .001), cerebrovascular disease (HR = 1.98; P < .001), and peripheral artery disease (HR = 1.76; P < .001).
SVI Mediates Disparities in Cardiovascular Outcomes
The median census tract overall SVI ranking was found to be significantly higher in Black vs White patients (77% vs 23%; P < .001), indicating greater social vulnerability among the former racial subgroup; these differences were consistently observed across all themes. A mediation analysis revealed that the SVI—specifically, the socioeconomic status theme—mediated 98% of the disparity in the risk of major adverse cardiovascular events between Black and White patients. According to the investigators, the effects of the other themes were less substantial.
The investigators concluded: “Black patients [with prostate cancer who were treated with ADT] have worse SVI [rankings] and are significantly more likely to experience major adverse cardiovascular events compared with White patients. The SVI, and particularly socioeconomic status, largely mediated the association between race and major adverse cardiovascular events.” The authors outlined the next steps for overcoming these disparities, which included conducting research to further understand and mitigate the needs of patients from socioeconomically vulnerable communities and implementing interventions to address social determinants of health.
Bonnie Ky, MD, MSCE, of the Perelman School of Medicine, University of Pennsylvania, Philadelphia, is the corresponding author of the JACC: CardioOncology article.
Disclosure: The study was funded by the American Heart Association and the National Institutes of Health. For full disclosures of the study authors, visit jacc.org.
