Better Data, Community Trust Necessary to Address CVD Disparities in Early-Onset CRC: Meng-Han Tsai, PhD

In part 2 of her interview with The American Journal of Managed Care^® (AJMC^®), Meng-Han Tsai, PhD, assistant professor at Augusta University, explored the key findings of her study, “Sex, Race and Ethnicity, and Rurality Disparities in Cardiovascular Death Among Adults With Early-Onset Colorectal Cancer: A Retrospective Cohort Analysis.”

She found that among patients with early-onset colorectal cancer (CRC), defined as CRC diagnosed before age 50, men and racial and ethnic minority patients living in urban areas face a disproportionately elevated risk of cardiovascular disease (CVD) death.

Tsai also called for further research combining comprehensive data from clinical and population-level sources, along with community-based efforts to build trust and improve survivorship care planning for these vulnerable groups.

This transcript has been lightly edited for clarity.

AJMC: The age-adjusted cardiovascular mortality rate in men was nearly 5 times that of women. What do you think is driving such a large gap?

Tsai: There are so many reasons we can think about for the men. A lot of the time, they have more chronic conditions compared with women, so that might be one of the reasons it happened before their cancer diagnosis, and it may make their treatment process more complicated. So, that's why it leads to the higher rates of CVD mortality compared with women.

Another reason we can also think about in general is that men are less likely to engage in any kind of health care compared with women. So, there are 2 possible reasons we can think about, but we definitely need a little bit more investigation.

AJMC: About 80% of the cohort underwent surgery, and approximately 58% received chemotherapy. How much of the cardiovascular mortality burden do you attribute to treatment-related effects vs shared underlying risk factors?

Tsai: Treatment definitely can impact CVD mortality. But based on what I read from all the literature, from the research, it seems shared risk factors also play an important role. Just like what I mentioned earlier, if they have a more chronic condition before the cancer diagnosis, that will make their treatment more complicated.

But the thing is, the data I'm using are more population-level. We definitely need a little bit more comprehensive data sources, like combined clinical data and also population-level data, to really understand if it is because of their prediagnosis chronic condition or any kind of cardiometabolic risk that links to the CVD deaths once they are diagnosed with CRC.

AJMC: The racial and ethnic disparities were concentrated in all-urban areas, challenging the idea that patients in rural areas face the greatest health disparities. Why do you think urban minority patients with early-onset CRC carry such a disproportionate cardiovascular burden?

Tsai: In general, we know that racial minorities already have a lack of resources or limited access to health care. Also, it is possible that they need a job. Living closer to the urban area may help them get access to a job without worrying about any other transportation. If you live in a rural area, you probably need to make sure you have a vehicle that can get you to work.

The thing is, socioeconomic status already kind of limits access to care. So, even though they're living in the urban area, we're thinking, “Oh, urban areas have more resources,” but for them, they probably still feel that, “No, we don't have insurance; we don't have primary care physicians. How can we get access to care?”

Also, for racial minorities, the other thing we have to think about is awareness. A lot of times, they don't realize they are at risk for certain diseases. That's why some of the community-based research is so important, because there is definitely some medical mistrust involved. We need some more community-based research to involve those certain populations to build trust and help them to get awareness, and definitely at a later point, they can get access to care.

AJMC: American Indian and Alaska Native patients faced more than triple the cardiovascular mortality risk of non-Hispanic White patients. In addition, Alaska Native people have the highest CRC rates worldwide. What do you think the cardio-oncology field is missing when it comes to addressing the needs of these populations?

Tsai: I feel this population is definitely tricky because they are considered underrepresented in a lot of research. That's why considering overall racial minority issues, like what I mentioned earlier, like lack of awareness and access to care, is important.

The other thing we have to do is try to build a little bit more trust and get more of them involved in the research process, because it also helps us to understand what the actual barriers are that they have. Each time we look at the data, those racial minority groups are just so small, and then we have to combine them, so it is very difficult to really know which group has a particular barrier. So, I think these are the key things in academia or the research area; we really need to think about how to explore these populations a little bit more.

AJMC: How should clinicians incorporate these findings into cardiovascular risk assessment and survivorship care planning for patients with early-onset CRC moving forward?

Tsai: Because the data source I'm using is not clinical, we definitely need a little bit more comprehensive data: combined clinical data and population-level data. My current findings, I hope, can at least bring a little bit of attention from the health care systems to younger patients who may be affected by CVD mortality, particularly in urban areas.

Then, we have to look at more upstream factors. Is it because health care is kind of overloaded and does not really pay attention to the younger population? They also need health care resources. Based on the cardio-oncology care, we think they can use this information to plan a little bit better for their survivorship care. The next step is really just what I mentioned: we need to further confirm whether it is their prediagnosis cardiometabolic risk factors that link to the cancer diagnosis and later trigger the higher risk for CVD mortality.