Neighborhood Contemporary Redlining and Racial Mortgage Lending Bias and Cardiovascular Outcomes in Women With Breast Cancer

BACKGROUND: Studies have demonstrated neighborhood structural inequities are associated with cardiovascular outcomes among breast cancer survivors. We investigated the associations between bias in mortgage lending practices (contemporary redlining and racial lending bias) and cardiovascular outcomes in women with breast cancer. METHODS: Using the SEER (Surveillance, Epidemiology, and End Results)-Medicare database, we identified 51 007 Black and White women diagnosed with breast cancer between 2010 and 2014 with follow-up through 2020. We used Home Mortgage Disclosure Act data to calculate census-tract contemporary redlining index and racial lending bias index, and assessed indices continuously and categorically (low, moderate, or high). We used Cox proportional hazards regression to estimate multivariable-adjusted, cause-specific hazard ratios (HRs) for major adverse cardiovascular events, ischemic heart disease, heart failure, stroke, and cardiovascular death. RESULTS: In the overall population, a 10%-unit increase in redlining was associated with increased risk of major adverse cardiovascular events (HR, 1.04 [95% CI, 1.02-1.06]). Among Black women, those in high redlining neighborhoods had an increased heart failure risk compared with those in low redlining neighborhoods (HR, 1.22 [95% CI, 1.05-1.41]). Similarly, White women in high redlining neighborhoods had an increased risk of ischemic heart disease (HR, 1.23 [95% CI, 1.15-1.30]) and stroke (HR, 1.09 [95% CI, 1.03-1.16]). Black women in high racial lending bias neighborhoods had reduced cardiovascular mortality risk compared with those in low racial lending bias neighborhoods (HR, 0.69 [95% CI, 0.54-0.90]). CONCLUSIONS: We identified associations between contemporary redlining and cardiovascular outcomes among breast cancer survivors. High racial lending bias was associated with reduced cardiovascular mortality risk among Black women. Bias in mortgage lending practices may serve as a structural driver of cardiovascular disparities.