Disparities In Heart Disease Mortality Research Articles

Racial and ethnic disparities in treatment-related heart disease mortality among US breast cancer survivors

Racial and ethnic disparities in heart disease mortality by initial treatment type among breast cancer survivors have not been well described. We included 739 557 women diagnosed with first primary invasive breast cancer between 2000 and 2017 (aged 18-84 years, received surgery, survived ≥1 year, followed through 2018) in the Surveillance, Epidemiology, and End Results-18 database. Standardized mortality ratios (SMRs; observed over expected) were calculated by race and ethnicity (non-Hispanic/Latina Asian American, Native Hawaiians, and other Pacific Islanders [AANHPI]; non-Hispanic/Latina Black [Black]; Hispanic/Latina [Latina]; and non-Hispanic/Latina White [White]) and initial treatment (surgery only; chemotherapy with surgery; chemotherapy, radiotherapy, with surgery; and radiotherapy with surgery) compared with the racial- and ethnic-matched general population, and by clinical characteristics. Cumulative heart disease mortality was estimated accounting for competing risks. SMRs were elevated for Black and Latina women treated with surgery only and chemotherapy with surgery (SMR range = 1.15-1.21) and AANHPI women treated with chemotherapy, radiotherapy, with surgery (SMR = 1.29; 95% confidence interval [CI] = 1.11 to 1.48), whereas SMRs were less than 1 for White women (SMR range = 0.70-0.96). SMRs were especially high for women with advanced (regional or distant) stage among Black women for all treatment (range = 1.15-2.89) and for AANHPI and Latina women treated with chemotherapy with surgery (range = 1.28-3.61). Non-White women diagnosed at younger than age 60 years had higher SMRs, as did Black and AANHPI women diagnosed with estrogen receptor-positive breast cancers. Black women had the highest 10-year cumulative risk of heart disease mortality: aged younger than 60 years (Black: 1.78%, 95% CI = 1.63% to 1.94%) compared with White, AANHPI, and Latina women (<1%) and aged 60 years and older (Black: 7.92%, 95% CI = 7.53% to 8.33%) compared with White, AANHPI, and Latina women (range = 3.90%-6.48%). Our findings illuminated striking racial and ethnic disparities in heart disease mortality among Black, AANHPI, and Latina breast cancer survivors, especially after initial chemotherapy receipt.

Abstract PR009: Role of treatment on racial and ethnic disparities in heart disease mortality among U.S. breast cancer survivors, 2000-2018

Abstract Background: Breast cancer survivors have an elevated risk of dying from heart disease, in part due to cardiotoxic cancer treatment, such as chemotherapy and radiotherapy. Differences in heart disease mortality by race/ethnicity and initial treatment receipt among U.S. breast cancer survivors have not been well described. Methods: We calculated standardized mortality ratios (SMRs; observed/expected) for heart disease among 739,557 first primary breast cancer survivors (diagnosed between 2000-2017; aged 18-84 years; survived 12+ months) in the U.S. Surveillance, Epidemiology, and End Results 18 registries, compared to the racial/ethnic matched general population. Analyses were examined by race/ethnicity: non-Hispanic White (White), non-Hispanic Black (Black), non-Hispanic/Latina Asian, Native Hawaiians, and Pacific Islanders (AANHPI), and Hispanic/Latina (Latina), and initial treatment: surgery only, chemotherapy alone, chemotherapy plus radiotherapy, and radiotherapy alone. SMRs were stratified by stage (localized/regional/distant), age at breast cancer diagnosis (&amp;lt;60, ≥60 years), and estrogen receptor (ER) status (positive/negative). P-heterogeneity was calculated with multivariable adjusted Poisson regression models and likelihood ratio tests. We estimated 10-year cumulative heart disease mortality, accounting for competing risks (i.e., non-heart disease deaths), by race/ethnicity and age at breast cancer diagnosis. Results: SMRs for heart disease mortality among breast cancer survivors varied by race/ethnicity (p-heterogeneity&amp;lt;0.05) and initial treatment; SMRs were elevated for Black and Latina women treated with surgery only and chemotherapy alone (range: 1.15-1.21) and AANHPI women treated with chemotherapy plus radiotherapy (SMR: 1.29, 95%CI: 1.11,1.48), whereas for White women, SMRs were &amp;lt;1.00 for all treatment (range: 0.70-0.96). SMRs were especially high for women with advanced (regional or distant stage) disease among Black women for all treatment (range: 1.15-2.89), and for AANHPI and Latina women treated with chemotherapy only (range: 1.28-3.61). Non-white women diagnosed at age &amp;lt;60 years had higher SMRs, as did Black and AANHPI women diagnosed with ER positive breast cancers. Black women had the highest ten-year cumulative risk of heart disease mortality: age &amp;lt;60 years (Black: 1.78%, 95%CI:1.63%,1.94%) compared to White, AANHPI, and Latina women (all &amp;lt;1%); and age 60+ years: Black (7.92%, 95%CI:7.53%,8.33%) compared to White, AANHPI, and Latina women (range: 3.90%-6.48%). Conclusions: Our findings illuminated striking disparities in heart disease mortality among Black, Latina, and AANHPI breast cancer survivors, especially after initial chemotherapy, and these disparities persisted across clinical characteristics. Future studies are needed to examine racial/ethnic disparities by detailed cancer treatment (including chemotherapy and targeted agents, endocrine therapy, and radiation dose) and lifestyle risk factors. Citation Format: Jacqueline B. Vo, Cody Ramin, Wayne Lawrence, Ana Barac, Katherine Ho, Jongeun Rhee, Lene H.S. Veiga, Amy Berrington de Gonzalez. Role of treatment on racial and ethnic disparities in heart disease mortality among U.S. breast cancer survivors, 2000-2018 [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PR009.

A likelihood ratio test on temporal trends in age-period-cohort models with applications to the disparities of heart disease mortality among US populations and comparison with Japan.

In this article, we introduce the recently developed intrinsic estimator method in the age-period-cohort (APC) models in examining disease incidence and mortality data, further develop a likelihood ratio (L-R) test for testing differences in temporal trends across populations, and apply the methods to examining temporal trends in the age, period or calendar time, and birth cohort of the US heart disease mortality across racial and sex groups. The temporal trends are estimated with the intrinsic estimator method to address the model identification problem, in which multiple sets of parameter estimates yield the same fitted values for a given dataset, making it difficult to conduct comparison of and hypothesis testing on the temporal trends in the age, period, and cohort across populations. We employ a penalized profile log-likelihood approach in developing the L-R test to deal with the issues of multiple estimators and the diverging number of model parameters. The identification problem also induces overparametrization of the APC model, which requires a correction of the degree of freedom of the L-R test. Monte Carlo simulation studies demonstrate that the L-R test performs well in the Type I error calculation and is powerful to detect differences in the age or period trends. The L-R test further reveals disparities of heart disease mortality among the US populations and between the US and Japanese populations.

State-level minimum wage and heart disease death rates in the United States, 1980–2015: A novel application of marginal structural modeling

Despite substantial declines since the 1960's, heart disease remains the leading cause of death in the United States (US) and geographic disparities in heart disease mortality have grown. State-level socioeconomic factors might be important contributors to geographic differences in heart disease mortality. This study examined the association between state-level minimum wage increases above the federal minimum wage and heart disease death rates from 1980 to 2015 among ‘working age’ individuals aged 35–64 years in the US. Annual, inflation-adjusted state and federal minimum wage data were extracted from legal databases and annual state-level heart disease death rates were obtained from CDC Wonder. Although most minimum wage and health studies to date use conventional regression models, we employed marginal structural models to account for possible time-varying confounding. Quasi-experimental, marginal structural models accounting for state, year, and state × year fixed effects estimated the association between increases in the state-level minimum wage above the federal minimum wage and heart disease death rates. In models of ‘working age’ adults (35–64 years old), a $1 increase in the state-level minimum wage above the federal minimum wage was on average associated with ~6 fewer heart disease deaths per 100,000 (95% CI: −10.4, −1.99), or a state-level heart disease death rate that was 3.5% lower per year. In contrast, for older adults (65+ years old) a $1 increase was on average associated with a 1.1% lower state-level heart disease death rate per year (b = −28.9 per 100,000, 95% CI: −71.1, 13.3). State-level economic policies are important targets for population health research.

Racial Disparities in Heart Disease Mortality in the 50 Largest U.S. Cities.

Heart disease is not only the leading cause of death in the U.S. but also the main contributor to racial disparities in life expectancy. Despite this, heart disease mortality rates and racial disparities in these rates are not readily available at the city level where they can be the most quickly and effectively addressed. We calculated age-adjusted heart disease mortality rates and corresponding racial rate ratios (RRs) and rate differences (RDs) for the non-Hispanic Black (Black) and non-Hispanic White (White) populations for the years 1990-1994 and 2005-2009 for the U.S. and the 50 largest cities therein. We then examined relationships between the disparities and city-level population indicators. Nationally, mortality rates were significantly higher among Blacks than Whites at both time periods. Larger improvements in rates for Whites compared to Blacks resulted in a significant increase in disparities over the 20-year period for 11 cities. There were 19,448 excess Black deaths in the U.S. annually. City-level income inequality, as well as the overall city and White median household income, contributed to these disparities. By identifying city-specific disparities and trends, health care providers, public health agencies, and researchers can target the areas with the most need and can look at cities without disparities for clues on how to best advance health equity in heart disease morbidity and mortality.

Decomposing Black-White Disparities in Heart Disease Mortality in the United States, 1973-2010: An Age-Period-Cohort Analysis.

Against the backdrop of late 20th century declines in heart disease mortality in the United States, race-specific rates diverged because of slower declines among blacks compared with whites. To characterize the temporal dynamics of emerging black-white racial disparities in heart disease mortality, we decomposed race-sex-specific trends in an age-period-cohort (APC) analysis of US mortality data for all diseases of the heart among adults aged ≥35 years from 1973 to 2010. The black-white gap was largest among adults aged 35-59 years (rate ratios ranged from 1.2 to 2.7 for men and from 2.3 to 4.0 for women) and widened with successive birth cohorts, particularly for men. APC model estimates suggested strong independent trends across generations ("cohort effects") but only modest period changes. Among men, cohort-specific black-white racial differences emerged in the 1920-1960 birth cohorts. The apparent strength of the cohort trends raises questions about life-course inequalities in the social and health environments experienced by blacks and whites which could have affected their biomedical and behavioral risk factors for heart disease. The APC results suggest that the genesis of racial disparities is neither static nor restricted to a single time scale such as age or period, and they support the importance of equity in life-course exposures for reducing racial disparities in heart disease.

Kramer and Casper Respond to "A-P-C... It's Easy as 1-2-3!".

We appreciate Dr. Harper's thoughtful and thorough commentary (1) on our paper (2). From our vantage point, there are more areas of agreement than disagreement. Although we do not deny being intrigued by the “buried epidemiologic treasure” of an observed cohort effect, our motivation was not to champion age-period-cohort (APC) analysis as a faultless method but instead to use the APC toolbox to examine another elusive process: the temporal evolution of a population health disparity. The ubiquity of racial disparities in health can make them seem inevitable. However, trends in black-white disparities in heart disease mortality suggest that such inequity is not a fixed constant but a time-varying phenomenon. Instead of examining why disparities arose, we focused on when they arose. As a descriptive tool, the APC toolbox—consisting of nonparametric graphical tools in addition to the 3-factor regression on which Dr. Harper primarily focused attention—offers a set of analytical approaches for describing the time components conflated in secular trends. Regrettably, several assumptions underpinning our analysis were left unclear. Our decision to constrain the first 2 periods in order to make the 3-factor regression identifiable reflected our somewhat unorthodox approach to APC analysis, which primarily examined rate ratios rather than rates. While the first 2 periods saw substantial secular declines in death rates, these periods also had relatively stable rate ratios. Regarding the scale for reporting disparity trends, Dr. Harper correctly notes that our reliance on the relative scale needed explanation (1), and we are grateful for his effort in producing complementary absolute measures. In general, we agree that both ratios and differences provide valuable information about the nature of health disparities, but in this setting we suggest that the relative scale measures fundamental mechanisms hypothesized in the evolution of health disparities. The dramatic declines in heart disease mortality rates for all groups over a period of 4 decades in the United States are impressive and meaningful. However, the “rising tide lifts all boats” perspective—all race-sex groups have lower rates now than in 1973—may obscure persistent patterns of unequal access to novel heart disease prevention efforts. One explanation for emerging disparities in the face of overall declines is that as new knowledge of heart disease prevention arises, economically advantaged groups gain access to the new knowledge and treatments before groups with less economic advantage (3). The result is not a complete exclusion from “progress” but instead delayed or incomplete access to its benefits. Because absolute rates are declining, the absolute difference may look good, while the relative gap more sensitively marks a disparity in the diffusion of progress. As we discussed (2) and Dr. Harper elaborated on (1), there are many pitfalls in APC analysis and the underlying assumptions necessary to gain useful information. However, we do not fully agree that there are “wildly differing” results among studies concerning the influence of period and cohort effects on racial differences in heart disease mortality. In contrast, we find a great deal of qualitative if not exact numerical agreement. Considering the question of when racial disparities emerge, Dr. Harper's analyses on both the relative and absolute scales are generally supportive of our conclusion (and the conclusion of Masters et al. (4), whom he cites) that cohort differences contributed more to racial disparities in heart disease mortality than did period differences. The largest difference in conclusions between our analysis and Harper's rate difference analysis is on the age scale: We reported large disparities among younger adults on the relative scale (2), but given lower rates at younger ages, these differences are quite small on the absolute scale. We argue that both truths are relevant. Ultimately, the APC toolbox accomplished the task for which it is suited: not making causal inferences but instead describing aspects of the temporal dynamics which make up secular trends. As with many descriptive tools, the results are hypothesis-generating, and the discussion engendered here has indeed raised several questions worthy of further study.

Trends and Disparities in Heart Disease Mortality Among American Indians/Alaska Natives, 1990–2009

We evaluated heart disease death rates among American Indians and Alaska Natives (AI/ANs) and Whites after improving identification of AI/AN populations. Indian Health Service (IHS) registration data were linked to the National Death Index for 1990 to 2009 to identify deaths among AI/AN persons aged 35 years and older with heart disease listed as the underlying cause of death (UCOD) or 1 of multiple causes of death (MCOD). We restricted analyses to IHS Contract Health Service Delivery Areas and to non-Hispanic populations. Heart disease death rates were higher among AI/AN persons than Whites from 1999 to 2009 (1.21 times for UCOD, 1.30 times for MCOD). Disparities were highest in younger age groups and in the Northern Plains, but lowest in the East and Southwest. In AI/AN persons, MCOD rates were 84% higher than UCOD rates. From 1990 to 2009, UCOD rates declined among Whites, but only declined significantly among AI/AN persons after 2003. Analysis with improved race identification indicated that AI/AN populations experienced higher heart disease death rates than Whites. Better prevention and more effective care of heart disease is needed for AI/AN populations.