Social Determinants of Health and Racial Disparities in Cardiac Events in Breast Cancer

Authors:
Nickolas Stabellini Graduate Education Office, Case Western Reserve University School of Medicine, Cleveland, Ohio
Department of Hematology-Oncology, University Hospitals Seidman Cancer Center, Cleveland, Ohio
Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio

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Mantas Dmukauskas Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio

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Marcio S. Bittencourt Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania

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Jennifer Cullen Cancer Population Sciences, Case Comprehensive Cancer Center, Cleveland, Ohio

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Amie J. Barda Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
Department of Pediatrics, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio

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Justin X. Moore Cancer Prevention, Control, and Population Health Program, Department of Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia

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Susan Dent Duke Cancer Institute, Department of Medicine, Duke University, Durham, North Carolina

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Husam Abdel-Qadir Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
Cardiovascular Division, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada

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Aniket A. Kawatkar Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, California

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Ambarish Pandey Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas

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John Shanahan Cancer Informatics, University Hospitals Seidman Cancer Center, Cleveland, Ohio

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Jill S. Barnholtz-Sloan Trans-Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
Center for Biomedical Informatics and Information Technology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland

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Kristin A. Waite Trans-Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland

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Alberto J. Montero Department of Hematology-Oncology, University Hospitals Seidman Cancer Center, Cleveland, Ohio

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Avirup Guha Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
Cardio-Oncology Program, Department of Cardiology, Medical College of Georgia, Augusta University, Augusta, Georgia

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Restricted access

Background: Racial disparities have been reported for breast cancer and cardiovascular disease (CVD) outcomes. The determinants of racial disparities in CVD outcomes are not yet fully understood. We aimed to examine the impact of individual and neighborhood-level social determinants of health (SDOH) on the racial disparities in major adverse cardiovascular events (MACE; consisting of heart failure, acute coronary syndrome, atrial fibrillation, and ischemic stroke) among female patients with breast cancer. Methods: This 10-year longitudinal retrospective study was based on a cancer informatics platform with electronic medical record supplementation. We included women aged ≥18 years diagnosed with breast cancer. SDOH were obtained from LexisNexis, and consisted of the domains of social and community context, neighborhood and built environment, education access and quality, and economic stability. Race-agnostic (overall data with race as a feature) and race-specific machine learning models were developed to account for and rank the SDOH impact in 2-year MACE. Results: We included 4,309 patients (765 non-Hispanic Black [NHB]; 3,321 non-Hispanic white). In the race-agnostic model (C-index, 0.79; 95% CI, 0.78–0.80), the 5 most important adverse SDOH variables were neighborhood median household income (SHapley Additive exPlanations [SHAP] score [SS], 0.07), neighborhood crime index (SS = 0.06), number of transportation properties in the household (SS = 0.05), neighborhood burglary index (SS = 0.04), and neighborhood median home values (SS = 0.03). Race was not significantly associated with MACE when adverse SDOH were included as covariates (adjusted subdistribution hazard ratio, 1.22; 95% CI, 0.91–1.64). NHB patients were more likely to have unfavorable SDOH conditions for 8 of the 10 most important SDOH variables for the MACE prediction. Conclusions: Neighborhood and built environment variables are the most important SDOH predictors for 2-year MACE, and NHB patients were more likely to have unfavorable SDOH conditions. This finding reinforces that race is a social construct.

Submitted January 27, 2023; final revision received March 15, 2023; accepted for publication March 20, 2023.

Author contributions: Study concept: Guha. Study design: Stabellini, Barnholtz-Sloan, Montero. Study conduct: Stabellini. Writing—original draft: Stabellini, Guha. Writing—review and editing: All authors.

Data availability statement: The University Hospitals (UH) Seidman Cancer Center database is available at UH Cleveland Medical Center, and access is restricted to researchers who have approval from the Institutional Review Board.

Disclosures: A. Pandey has disclosed receiving grant/research support from Gilead Sciences, Applied Therapeutics, and HeartSciences; serving as a principal investigator for Applied Therapeutics, Gilead Sciences, and SC Pharmaceuticals; serving on an advisory board for Roche Diagnostics, Lilly USA, Bayer, and Cytokinetics; and serving as a consultant for Tricog Health Inc., Rivus, Emmi Solutions, Axon Therapies, Sarfez Pharmaceuticals, Science 37, Alleviant Medical, Palomarin Inc., and Pieces Technologies. The remaining authors have disclosed that they have not received any financial considerations from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: N. Stabellini is supported through funding from the Sociedade Beneficente Israelita Brasileira Albert Einstein on the program Marcos Lottenberg & Marcos Wolosker International Fellowship for Physicians Scientists – Case Western. A. Guha is supported by the American Heart Association—Strategically Focused Research Network Grants in Disparities in Cardo-Oncology (#847740, #863620). This work was supported by ACHIEVE GreatER (Addressing Cardiometabolic Health Inequities by Early PreVEntion in the Great LakEs Region).

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. None of the funders had any role in the conduct of the study; in the collection, management, analysis, or interpretation of the data; or in the preparation, review, or approval of the manuscript.

Correspondence: Nickolas Stabellini, BS, University Hospitals Seidman Cancer Center, Department of Hematology-Oncology, Breen Pavilion, 11100 Euclid Avenue, Cleveland, OH 44106. Email: nickolas@case.edu

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  • 1.

    Sung H, Ferlay J, Siegel RL, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021;71:209249.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Surveillance, Epidemiology, and End Results Program. Cancer stat facts: female breast cancer. Accessed June 1, 2022. Available at: https://seer.cancer.gov/statfacts/html/breast.html

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Siegel RL, Miller KD, Wagle NS, et al. Cancer statistics, 2023. CA Cancer J Clin 2023;73:1748.

  • 4.

    Mehta LS, Watson KE, Barac A, et al. Cardiovascular disease and breast cancer: where these entities intersect: a scientific statement from the American Heart Association. Circulation 2018;137:e3066.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    American Cancer Society. Cancer treatment & survivorship facts & figures. Accessed September 9, 2021. Available at: https://www.cancer.org/research/cancer-facts-statistics/survivor-facts-figures.html

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Coughlin SS, Ayyala D, Majeed B, et al. Cardiovascular disease among breast cancer survivors. Cardiovasc Disord Med 2020;2:10.31489.

  • 7.

    Mery B, Fouilloux A, Rowinski E, et al. Cardiovascular disease events within 5 years after a diagnosis of breast cancer. BMC Cancer 2020;20:337.

  • 8.

    Chou YH, Huang JY, Kornelius E, et al. Major adverse cardiovascular events after treatment in early-stage breast cancer patients receiving hormone therapy. Sci Rep 2020;10:1408.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Ellis L, Canchola AJ, Spiegel D, et al. Racial and ethnic disparities in cancer survival: the contribution of tumor, sociodemographic, institutional, and neighborhood characteristics. J Clin Oncol 2018;36:2533.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Sparano JA, Brawley OW. Deconstructing racial and ethnic disparities in breast cancer. JAMA Oncol 2021;7:355356.

  • 11.

    Brothers RM, Fadel PJ, Keller DM. Racial disparities in cardiovascular disease risk: mechanisms of vascular dysfunction. Am J Physiol Heart Circ Physiol 2019;317:H777789.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation 2019;139:e56528.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Howlader N, Noone A, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2014, National Cancer Institute. Bethesda, MD. Based on November 2016 SEER data submission, posted to the SEER web site, April 2017. Accessed July 6, 2022. Available at: https://seer.cancer.gov/csr/1975_2014/

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Al-Sadawi M, Hussain Y, Copeland-Halperin RS, et al. Racial and socioeconomic disparities in cardiotoxicity among women with HER2-positive breast cancer. Am J Cardiol 2021;147:116121.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Stabellini N, Dmukauskas M, Cullen J, et al. Racial disparities in zip-code level social determinants of health and cardiovascular outcomes in females with breast cancer. Circulation 2022;146(Suppl 1):Abstract 11546.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    National Cancer Institute. Cancer Moonshot. Accessed October 6, 2022. Available at: https://www.cancer.gov/research/key-initiatives/moonshot-cancer-initiative

  • 17.

    Battisti NML, Welch CA, Sweeting M, et al. Prevalence of cardiovascular disease in patients with potentially curable malignancies: a national registry dataset analysis. JACC CardioOncol 2022;4:238253.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    University Hospitals. Annual report 2021. Accessed March 5, 2023. Available at: https://www.uhhospitals.org/about-uh/publications/UH-Annual-Report/2021-annual-report

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Caisis. What is Caisis? Accessed April 15, 2021. Available at: http://www.caisis.org/

  • 20.

    Stabellini N, Bruno DS, Dmukauskas M, et al. Sex differences in lung cancer treatment and outcomes at a large hybrid academic-community practice. JTO Clin Res Rep 2022;3:100307.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Stabellini N, Chandar AK, Chak A, et al. Sex differences in esophageal cancer overall and by histological subtype. Sci Rep 2022;12:5248.

  • 22.

    Stabellini N, Cullen J, Cao L, et al. Racial disparities in breast cancer treatment patterns and treatment related adverse events. Sci Rep 2023;13:1233.

  • 23.

    Stabellini N, Tomlinson B, Cullen J, et al. Sex differences in adults with acute myeloid leukemia and the impact of sex on overall survival. Cancer Med 2023;12:67116721.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    EMERSE. Electronic Medical Record Search Engine. Accessed May 16, 2022. Available at: https://project-emerse.org/index.html

    • PubMed
    • Export Citation
  • 25.

    ICD-10 Version:2019. Accessed July 23, 2021. Available at: https://icd.who.int/browse10/2019/en

    • PubMed
    • Export Citation
  • 26.

    Centers for Disease Control and Prevention. International Classification of Diseases, Ninth Revision (ICD-9). Accessed July 23, 2021. Available at: https://www.cdc.gov/nchs/icd/icd9.htm

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Healthy Northeast Ohio. Community homepage. Accessed March 6, 2023. Available at: https://www.healthyneo.org/

  • 28.

    LexisNexis. Social determinants of health. Accessed May 3, 2022. Available at: https://risk.lexisnexis.com/healthcare/social-determinants-of-health

  • 29.

    Healthy People 2030. Social determinants of health. Accessed May 3, 2022. Available at: https://health.gov/healthypeople/priority-areas/social-determinants-health

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Centers for Medicare & Medicaid Services. Accountable care organizations (ACOs): general information. Accessed October 19, 2022. Available at: https://innovation.cms.gov/innovation-models/aco

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Bonsu JM, Guha A, Charles L, et al. Reporting of cardiovascular events in clinical trials supporting FDA approval of contemporary cancer therapies. J Am Coll Cardiol 2020;75:620628.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Rahman F, Ko D, Benjamin EJ. Association of atrial fibrillation and cancer. JAMA Cardiol 2016;1:384386.

  • 33.

    Guha A, Dey AK, Arora S, et al. Contemporary trends and outcomes of percutaneous and surgical aortic valve replacement in patients with cancer. J Am Heart Assoc 2020;9:e014248.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373383.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Kerr AJ, Broad J, Wells S, et al. Should the first priority in cardiovascular risk management be those with prior cardiovascular disease? Heart 2009;95:125129.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Segar MW, Hall JL, Jhund PS, et al. Machine learning-based models incorporating social determinants of health vs traditional models for predicting in-hospital mortality in patients with heart failure. JAMA Cardiol 2022;7:844854.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37.

    Lewis EF. Machine learning and social determinants of health-an opportunity to move beyond race for inpatient risk prediction in patients with heart failure. JAMA Cardiol 2022;7:854855.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38.

    Azuaje F. Artificial intelligence for precision oncology: beyond patient stratification. NPJ Precis Oncol 2019;3:6.

  • 39.

    Sonabend R, Király FJ, Bender A, et al. mlr3proba: an R package for machine learning in survival analysis. Bioinformatics 2021;37:27892791.

  • 40.

    Lundberg SM, Erion G, Chen H, et al. From local explanations to global understanding with explainable AI for trees. Nat Mach Intell 2020;2:5667.

  • 41.

    Chen T, Guestrin C. XGBoost: a scalable tree boosting system. Accessed May 3, 2022. Available at: https://dl.acm.org/doi/pdf/10.1145/2939672.2939785

  • 42.

    Xu Y, Goodacre R. On splitting training and validation set: a comparative study of cross-validation, bootstrap and systematic sampling for estimating the generalization performance of supervised learning. J Anal Test 2018;2:249262.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43.

    Pudjihartono N, Fadason T, Kempa-Liehr AW, et al. A review of feature selection methods for machine learning-based disease risk prediction. Accessed September 5, 2022. Available at: https://www.frontiersin.org/articles/10.3389/fbinf.2022.927312/full

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44.

    Refaeilzadeh P, Tang L, Liu H. Cross-validation. In: Liu L, Özsu MT, eds. Encyclopedia of Database Systems. Springer; 2009:532538.

  • 45.

    Harrell FE Jr, Califf RM, Pryor DB, et al. Evaluating the yield of medical tests. JAMA 1982;247:25432546.

  • 46.

    Lundberg SM, Lee SI. A unified approach to interpreting model predictions. Accessed July 25, 2022. Available at: https://dl.acm.org/doi/10.5555/3295222.3295230

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47.

    Friedman JH. Greedy function approximation: a gradient boosting machine. Ann Statist 2001;29:11891232.

  • 48.

    Goldstein A, Kapelner A, Bleich J, et al. Peeking inside the black box: visualizing statistical learning with plots of individual conditional expectation. J Comp Graph Stat 2015;24:4465.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 49.

    von Elm E, Altman DG, Egger M, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008;61:344349.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50.

    Yedjou CG, Sims JN, Miele L, et al. Health and racial disparity in breast cancer. Adv Exp Med Biol 2019;1152:3149.

  • 51.

    Akinyemiju T, Moore JX, Ojesina AI, et al. Racial disparities in individual breast cancer outcomes by hormone-receptor subtype, area-level socio-economic status and healthcare resources. Breast Cancer Res Treat 2016;157:575586.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52.

    Muncan B. Cardiovascular disease in racial/ethnic minority populations: illness burden and overview of community-based interventions. Public Health Rev 2018;39:32.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 53.

    Kurian AK, Cardarelli KM. Racial and ethnic differences in cardiovascular disease risk factors: a systematic review. Ethn Dis 2007;17:143152.

  • 54.

    Fei K, Rodriguez-Lopez JS, Ramos M, et al. Racial and ethnic subgroup disparities in hypertension prevalence, New York City Health and Nutrition Examination Survey, 2013–2014. Prev Chronic Dis 2017;14:E33.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55.

    Tammemagi CM. Racial/ethnic disparities in breast and gynecologic cancer treatment and outcomes. Curr Opin Obstet Gynecol 2007;19:3136.

  • 56.

    Hirschman J, Whitman S, Ansell D. The black:white disparity in breast cancer mortality: the example of Chicago. Cancer Causes Control 2007;18:323333.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 57.

    Mensah GA, Mokdad AH, Ford ES, et al. State of disparities in cardiovascular health in the United States. Circulation 2005;111:12331241.

  • 58.

    Kidambi S, Kotchen JM, Grim CE, et al. Association of adrenal steroids with hypertension and the metabolic syndrome in blacks. Hypertension 2007;49:704711.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 59.

    Kaul P, Lytle BL, Spertus JA, et al. Influence of racial disparities in procedure use on functional status outcomes among patients with coronary artery disease. Circulation 2005;111:12841290.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 60.

    Gillum RF. Stroke in blacks. Stroke 1988;19:19.

  • 61.

    Guha A, Fradley MG, Dent SF, et al. Incidence, risk factors, and mortality of atrial fibrillation in breast cancer: a SEER-Medicare analysis. Eur Heart J 2022;43:300312.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 62.

    Guha A, Stabellini N, Montero AJ. Commentary: longitudinal changes in circulating metabolites and lipoproteins after breast cancer treatment. Front Cardiovasc Med 2022;9:962698.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 63.

    Paterson DI, Wiebe N, Cheung WY, et al. Incident cardiovascular disease among adults with cancer: a population-based cohort study. JACC CardioOncol 2022;4:8594.

  • 64.

    Koene RJ, Prizment AE, Blaes A, et al. Shared risk factors in cardiovascular disease and cancer. Circulation 2016;133:11041114.

  • 65.

    Powell-Wiley TM, Baumer Y, Baah FO, et al. Social determinants of cardiovascular disease. Circ Res 2022;130:782799.

  • 66.

    Tucker-Seeley RD. Social determinants of health and disparities in cancer care for Black people in the United States. JCO Oncol Pract 2021;17:261263.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 67.

    Vince RA Jr, Eyrich NW, Mahal BA, et al. Reporting of racial health disparities research: are we making progress? J Clin Oncol 2022;40:811.

  • 68.

    Stanley J, Harris R, Cormack D, et al. The impact of racism on the future health of adults: protocol for a prospective cohort study. BMC Public Health 2019;19:346.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 69.

    Williams DR, Mohammed SA. Racism and health I: pathways and scientific evidence. Am Behav Sci 2013;57:11521173.

  • 70.

    Jones CP. Confronting institutionalized racism. Phylon 2002;50:722.

  • 71.

    Ganatra S, Dani SS, Kumar A, et al. Impact of social vulnerability on comorbid cancer and cardiovascular disease mortality in the United States. JACC CardioOncol 2022;4:326337.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 72.

    Stabellini N, Cullen J, Moore JX, et al. Racial differences in chronic stress/allostatic load variation due to androgen deprivation therapy in prostate cancer. JACC CardioOncol 2022;4:555557.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 73.

    Equal Justice Initiative. Racial justice. Accessed January 21, 2022. Available at: https://eji.org/racial-justice/

  • 74.

    Paradies Y, Ben J, Denson N, et al. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One 2015;10:e0138511.

  • 75.

    Paradies Y. Defining, conceptualizing and characterizing racism in health research. Crit Public Health 2006;16:143157.

  • 76.

    Krieger N. Methods for the scientific study of discrimination and health: an ecosocial approach. Am J Public Health 2012;102:936944.

  • 77.

    Williams DR, Sternthal M. Understanding racial-ethnic disparities in health: sociological contributions. J Health Soc Behav 2010;51(Suppl l):S1527.

  • 78.

    Freeman HP, Chu KC. Determinants of cancer disparities: barriers to cancer screening, diagnosis, and treatment. Surg Oncol Clin N Am 2005;14:655669.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 79.

    Carnethon MR, Pu J, Howard G, et al. Cardiovascular health in African Americans: a scientific statement from the American Heart Association. Circulation 2017;136:e393423.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 80.

    Mital R, Bayne J, Rodriguez F, et al. Race and ethnicity considerations in patients with coronary artery disease and stroke: JACC Focus Seminar 3/9. J Am Coll Cardiol 2021;78:24832492.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 81.

    Ntusi NAB, Sliwa K. Impact of racial and ethnic disparities on patients with dilated cardiomyopathy: JACC Focus Seminar 7/9. J Am Coll Cardiol 2021;78:25802588.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 82.

    Kuzawa CW, Sweet E. Epigenetics and the embodiment of race: developmental origins of US racial disparities in cardiovascular health. Am J Hum Biol 2009;21:215.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 83.

    Schneider EC, Chin MH, Graham GN, et al. Increasing equity while improving the quality of care: JACC Focus Seminar 9/9. J Am Coll Cardiol 2021;78:25992611.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 84.

    Rothstein R. The Color of Law: A Forgotten History of How Our Government Segregated America. Liveright Publishing; 2017.

  • 85.

    Bailey ZD, Feldman JM, Bassett MT. How structural racism –orks - racist policies as a root cause of U.S. racial health inequities. N Engl J Med 2021;384:768773.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 86.

    Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annu Rev Public Health 2019;40:105125.

  • 87.

    Williams DR, Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Rep 2001;116:404416.

  • 88.

    Schultz WM, Kelli HM, Lisko JC, et al. Socioeconomic status and cardiovascular outcomes: challenges and interventions. Circulation 2018;137:21662178.

  • 89.

    Rosengren A, Hawken S, Ounpuu S, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case-control study. Lancet 2004;364:953962.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 90.

    Stabellini N, Cullen J, Bittencourt MS, et al. Allostatic load and cardiovascular outcomes in males with prostate cancer. JNCI Cancer Spectrum 2023;7:pkad005. https://academic.oup.com/jncics/article/7/2/pkad005/7031248

    • PubMed
    • Search Google Scholar
    • Export Citation
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