Rurality Status and Cardiovascular Events/Survival in Older Men With Prostate Cancer
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Department of Hematology-Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH
Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA
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Institute of Public and Preventive Health, Augusta University, Augusta, GA
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Cardio-Oncology Program, Medical College of Georgia at Augusta University, Augusta, GA
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Cardio-Oncology Program, Medical College of Georgia at Augusta University, Augusta, GA
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Background: Rural areas have higher cardiovascular disease (CVD) incidence and age-adjusted mortality rates in the general population. However, the impact of rurality on CVD development and outcomes in patients with prostate cancer (PC) remains unclear. Patients and Methods: This retrospective cohort study used the SEER-Medicare database to analyze males aged ≥65 years diagnosed with PC between 2009 and 2017. The primary exposures were patient rurality status (metropolitan, urban, or rural) and patient–provider rurality, which combined the provider’s status (metropolitan vs nonmetropolitan) with the patient’s rurality. The primary outcomes included post-PC CVD (comprising heart failure, atrial fibrillation, acute myocardial infarction, peripheral artery disease, and ischemic stroke), cardiovascular mortality (CVDm), prostate cancer–specific mortality (PCSm), and all-cause mortality. Multivariable Fine-Gray and extended Cox models were used to assess the impact of rurality impact on these outcomes. Results: A total of 103,327 older men were included in the study, of whom 3,631 were from rural areas and 1,857 were rural patients with nonmetropolitan providers. Compared with metropolitan patients, those from rural areas had a 28% higher risk of PCSm (subdistribution hazard ratio [SHR], 1.28; 95% CI, 1.14–1.44) and a 15% higher risk of all-cause mortality (adjusted hazard ratio [aHR], 1.15; 95% CI, 1.07–1.23). Compared with urban patients, rural patients had a 7% higher risk of CVD (SHR, 1.07; 95% CI, 1.01–1.13). No significant differences were observed in CVDm. Among patients receiving androgen deprivation therapy (n=16,811), rurality was associated with a 27% higher risk of PCSm (SHR, 1.27; 95% CI, 1.07–1.51) and a 29% higher risk of all-cause mortality (aHR, 1.29; 95% CI, 1.12–1.49). Rural patients who received care from nonmetropolitan providers had higher risks of PCSm and all-cause mortality compared with those treated by metropolitan providers. Conclusions: Rurality is associated with higher risks of CVD, PCSm, and all-cause mortality compared with metropolitan and urban patients. Provider rurality further increases these risks, underscoring the critical role of health care access and quality in rural health disparities.
Submitted July 4, 2024; final revision received December 2, 2024; accepted for publication December 3, 2024. Published online March 12, 2025.
S. Jiang, V. Patel, and N. Stabellini contributed equally are co-first authors.
Previous presentation: The contents of this study were presented as a poster at the American Heart Association Scientific Sessions 2023, November 11–13, 2023, Philadelphia, PA (Abstract 14846); the 2024 ASCO Genitourinary Cancers Symposium, January 25–27, 2024, San Francisco, California (Abstract 265); and the ESC Congress 2024, August 30–September 2, 2024, London, United Kingdom (Abstract 3156).
Author contributions: Study concept: Jiang, Patel, Guha. Study design: Jiang, Patel, Stabellini, Guha. Data analysis: Stabellini. Writing—original draft: Jiang, Patel, Stabellini, Guha. Writing—review & editing: All authors.
Data availability statement: The SEER-Medicare dataset used in this study is available for research purposes upon request and approval from the National Cancer Institute and the Centers for Medicare & Medicaid Services. Researchers interested in accessing the data can submit a data use agreement application to the appropriate authorities. Further information on accessing SEER-Medicare data can be found on https://healthcaredelivery.cancer.gov/seermedicare/obtain/requests.html.
Funding: This work was supported by funding from American Heart Association (847740 and 863620; A. Guha) and the U.S. Department of Defense (HT94252310158; A. Guha). Research reported in this publication was supported in part by the Biostatistics Shared Resource of Winship Cancer Institute of Emory University and NIH/NCI under award number P30CA138292.
Disclosures: The authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Section 103885; Centers for Disease Control and Prevention’s National Program of Cancer Registries, under cooperative agreement 1NU58DP007156; the National Cancer Institute’s SEER Program under contract HHSN261201800032I awarded to the University of California, San Francisco, contract HHSN261201800015I awarded to the University of Southern California, and contract HHSN261201800009I awarded to the Public Health Institute. The ideas and opinions expressed herein are those of the author(s) and do not necessarily reflect the opinions of the State of California, Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their contractors and subcontractors.
Supplementary material: Supplementary material associated with this article is available online at https://doi.org/10.6004/jnccn.2024.7094. The supplementary material has been supplied by the author(s) and appears in its originally submitted form. It has not been edited or vetted by JNCCN. All contents and opinions are solely those of the author. Any comments or questions related to the supplementary materials should be directed to the corresponding author.
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