AHA: Address biological mechanisms, diversity, biases to improve cardio-oncology care
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Key takeaways:
- Women and underrepresented groups experience disparate cardio-oncology care and outcomes.
- The AHA issued strategies to reduce inequities in cardio-oncology research and clinical practice.
Underrepresented groups face elevated cardiotoxic risk and strategies are needed to eliminate inequities in cardio-oncology research and clinical care, according to a scientific statement published in Circulation.
Together, the American Heart Association Cardio-Oncology Committee of the Council on Clinical Cardiology and Council on Genomic and Precision Medicine; Council on Cardiovascular and Stroke Nursing; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; and the Council on Cardiovascular Radiology and Intervention issued a call to action to correct observed sex- and race-based inequities in cardio-oncology trials, registries and clinical practice.
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“Increasingly we've appreciated in clinic and in patient care that amongst cancer survivors and patients actively receiving cancer treatment, there appears to be significant disparity in terms of the rate and incidences and even sometimes the severity of CVD,” Daniel Addison, MD, clinical investigator and practicing cardiologist at Ohio State University and chair of the statement writing group, told Healio. “For this reason, and because of the mounting evidence around the potential for these disparities to affect long-term outcomes, we sought to pursue this collaborative consensus statement focused around this issue.”
Inequities in cardio-oncology
The committee reported that across 202 phase 2 and 3 anticancer therapy clinical trials, women experienced a 34% increased risk for severe adverse events from any cancer therapy and a 66% increased risk for cardiotoxicity from immune checkpoint inhibitors compared with men.
Additionally, obesity was associated with increased risk for breast cancer and CVD, especially among postmenopausal women, and breast cancer therapies — including anthracyclines and trastuzumab (Herceptin, Genentech) — were associated with an up to 14% increased incidence of cardiac dysfunction, according to the report.
Black patients with cancer experienced an approximately threefold increased risk for cardiotoxicity after anthracycline therapy and a twofold increased risk for cardiotoxicity after human epidermal growth factor receptor 2 (HER2) inhibitor treatment compared with white patients, Addison and colleagues wrote.
Even after adjusting for socioeconomic, cancer stage and cancer treatment-related factors, data also showed that Black patients experience increased risk for CVD and mortality after cancer diagnosis, according to the statement.
In addition, Hispanic patients were less likely receive an early cancer diagnosis compared with non-Hispanic white patients, and with delayed treatment, presented with later-stage cancer and more complex CVD, and are thus restricted to more cardiotoxic therapies and less eligible for novel treatments, the committee wrote.
The statement also detailed cardio-oncology disparities observed among Asian and Pacific Islanders as well as pediatric population and the LGBTQ community.
“Some of the most urgent gaps are understanding the root causes of some of the increased rates of cardiotoxicity that we see in underrepresented groups, particularly Black, Hispanic and Native American groups, as well as some of the disease manifestations that we see with relatively unique causes or mechanisms in women and underrepresented groups,” Addison told Healio.
He added that this statement highlights the importance of “Leveraging both collaborative cancer organizational and heart organizational efforts to systemically understand and address the issues that appear to be affecting a number of patients that we see in clinic.”
Drivers of disparity and strategies to improve
Drivers of disparity in cardio-oncology research and clinical practice include social determinants of health such as poverty, neighborhood disadvantage, discrimination, poor social support and social isolation; limited access to follow-up and uninsured status after anticancer therapy; environmental and psychosocial stressors brought on by structural racism; patient/health care professional racial concordance and workplace representation; and absence of diversity in clinical trials.
The writing committee recommended the following approaches to improve cardio-oncology research and health care equity:
- Investigate biological mechanisms to better understand how the effects of specific anticancer therapeutics could differ between groups to further tailor care toward precision medicine.
- Because CV risk factors disproportionately affect historically underrepresented populations, increasing diversity in clinical trials can reduce outcome disparities.
- Consider social determinants of health in cardio-oncology care, such as fiscally conscious optimal care.
- Utilize telehealth to increase access and utilize technology designed with equity in mind, such as interfaces with various language options.
- Reduce bias with training designed to instruct health care professionals to identify implicit bias.
“This statement tries to encapsulate diverse opinions from leaders in the field of cardio-oncology. To that end, we're hopeful that this consensus document will serve to solidify a step forward for the field of cardio-oncology and all patients affected by cancer and or heart diseases going forward,” Addison said.
Please see the statement for full details on addressing health inequities in cardio-oncology.
For more information:
Daniel Addison, MD, can be reached at daniel.addison@osumc.edu.
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