Healthcare disparities in cardio oncology: patients receive same level of surveillance regardless of race at a safety net hospital

Abstract

Background Cardiotoxicity remains a dreaded complication for patients undergoing chemotherapy with human epidermal growth factor (HER)-2 receptor antagonists and anthracyclines. Though many studies have looked at racial disparities in heart failure patients, minimal data is present for the cardio-oncology population. Methods We queried the echocardiogram database at a safety net hospital, defined by a high proportion of patients with Medicaid or no insurance, for patients who received HER2 receptor antagonists and/or anthracyclines from January 2016 to December 2018. Patient demographics, clinical characteristics, and treatment outcomes were collected. Based on US census data in 2019, home ZIP codes were used to group patients into quartiles based on median annual household income. The primary end point studied was referral rate to cardiology for patients undergoing chemotherapy. Results We identified 149 patients who had echocardiograms and also underwent treatment with HER2 receptor antagonists and/or anthracyclines, of which 70 (47.0%) were referred to the cardio-oncology program at our institution. Basic demographics were similar, but white patients were more likely to live in ZIP codes with higher income quartiles (p < 0.00001). Comparing between racial groups, there was no statistical difference in the percentage of patients that had a reduction in ejection fraction (EF) (p = 0.75). There was no statistical difference between racial groups in the number of cardiology or oncology appointments attended, number of appointments cancelled, average number of echocardiograms received, additional cardiac imaging received. Black patients were more likely to receive ACEI/ARB post chemotherapy (p = 0.047). A logistic regression model was created using race, age, gender, insurance, income quartile by home ZIP code, comorbidities (hypertension, hyperlipidemia, coronary artery disease, arrhythmia, diabetes mellitus, smoking, family history, age > 65), procedures (coronary stents, cardiac surgery), medications pre-chemotherapy, cancer type, cancer stage, and chemotherapy. This model found that there was an increased referral rate among patients from higher income quartiles (p = 0.017 for quartile 3, p = 0.049 for quartile 4), patients with a history of hypertension (p < 0.0001), and patients with breast cancer (p = 0.02). Conclusions The results of this study suggest that patients of our cardio-oncology population at a safety net hospital receive the same level of surveillance and treatment, and develop drop in ejection fraction at similar rates regardless of their race. However, patients that reside in ZIP codes associated with higher income quartiles, with hypertension, and with breast cancer, are associated with increased rate of referral.

Cardiovascular Imaging in Contemporary Cardio-Oncology: A Scientific Statement From the American Heart Association

“…Yet, a recent study of 149 patients (68 Black, 41 White, 33 Hispanic) from a safety net hospital who had undergone HER2-targeted therapy or anthracyclines for breast cancer found no statistical difference in the percentage of patients who had surveillance imaging to monitor for a reduction in LVEF. 95 These patients had been referred to a cardio-oncology clinic for cardiovascular care, suggesting a referral pattern with meticulous serial imaging and biomarker follow-up assessments that might benefit disparities in care.…”

Disparities in Cardio-oncology: Effects On Outcomes and Opportunities for Improvement

“…A recent study of 149 patients at a safety net hospital undergoing chemotherapy with trastuzumab and/or doxorubicin with 46% Blacks, 27.5% Whites, and 22% Hispanics reported that all populations received the same level of surveillance and treatment, leading to similar outcomes for cardiotoxicity regardless of the race even though White patients were more likely to live in high-income areas [ 30 ]. Thus, it is possible to attain equitable outcomes even in underprivileged populations with accessible healthcare.…”

Racial Disparities in Cardiovascular Disease Among Patients with Cancer in the United States: The Elephant in the Room

“…A retrospective analysis of 149 patients who received human epidermal growth factor receptor 2 ( HER2) receptor antagonists and/or anthracyclines showed lower rates of referrals among patients belonging to areas associated with lower income quartiles. 8 Access to cardio-oncology services is restricted by factors such as lack of funding and infrastructure. Most cardio-oncology clinics are limited to larger institutions that patients with relatively poorer socioeconomic backgrounds may not have access to.…”