Neighborhood-Level Social Determinants of Health and Cardiovascular Burden in Adolescent and Young Adult Patients Treated for Hodgkin Lymphoma
Authors: Rodriguez Elizabeth , El-Mallawany Nader Kim , Ahmed Sairah , Cuglievan Branko , Livingston John Andrew , Flowers Christopher R. , Xiao Qian , Roth Michael E. , Hildebrandt Michelle A.T. 
Published: December 2024

Background: High survival rates exist for adolescents and young adults (AYA) with Hodgkin Lymphoma (HL) with many survivors living decades post-treatment. Yet, late-term cardiovascular effects are present to a greater degree than the general population resulting in adverse effects on health and overall well-being. This has been attributed to the historic use of cardiotoxic chemotherapy and radiation to the chest. Previous work demonstrated racial and ethnic disparities in cardiovascular burden during survivorship, which may be exacerbated by social determinants of health (SDoH). We previously reported a 10% increase in risk of poor survival among AYA cancer patients that lived in neighborhoods with high burden of adverse SDoH measures (Rodriguez et al. JNCI Cancer Spectrum. 2024). However, little is known about the influence of neighborhood SDoH on cardiovascular burden in a diverse AYA HL patient population.

Methods: This study utilized a multi-ethnic cohort of AYA cancer patients treated for HL (N=974) diagnosed between ages 15-39 seen at MD Anderson Cancer Center. Patient demographics, zip code at presentation, and follow-up were acquired from the institutional cancer registry. Clinical characteristics obtained via the electronic medical record included cardiovascular diagnoses, time to first cardiovascular diagnosis, cancer stage, and treatment regimens. Zip codes were linked to Area Deprivation Index (ADI) values, a validated neighborhood-level SDoH measure, with higher ADI representing worse SDoH. Differences in patient characteristics by ADI were tested using student's t-test, chi-squared analysis, or ANOVA. Logistic regression analysis was performed to assess the risk of cardiovascular disease by ADI.

Results: The cohort included 727 (74.6%) White, 84 (8.6%) Black, and 163 (16.7%) Hispanic AYA HL patients with a median follow-up of 9.7 years. ADI values were significantly higher (p&lt;0.05) for Black (60.4) and Hispanic (63.9) patients, compared to White (50.9) patients. Less than 20% of White patients resided neighborhoods with the worst deprivation levels (highest ADI quartile) compared to 37.4% and 42.0% for Black and Hispanic patients, respectively. Black (7.7 years) and Hispanic (8.1 years) patients had significantly shorter time to cardiovascular events than their White (9.9 years) counterparts (p&lt;0.001) among those who developed cardiovascular disease. However, residing in a neighborhood with a higher ADI (worse SDoH) was not associated with increased risk of developing cardiovascular disease when testing ADI as quartiles or as a continuous variable (p&gt;0.05). No differences in time to cardiovascular event between ADI quartiles was observed (p&gt;0.48).

Conclusion: Our results in this diverse HL cohort suggest that cardiovascular dysfunction occurring after cancer treatment is not impacted by neighborhood-level SDoH in a single academic setting. Furthermore, time to cardiovascular event did not differ based on SDoH. The only differences noted in cardiovascular burden were between race/ethnicity groups as seen in previous studies, reflecting the persistent disparities in late-term effects of treatment. Further research comparing these results to those from other cancer care settings would aid in understanding the relationship between SDoH and cardiovascular burden in HL AYA patients more broadly.