Socioeconomic position as a social determinant of health and its effect on cardiovascular outcomes and mortality in patients with prostate cancer: A SEER-Medicare based study.
Authors: Nahle Tarek , Elsayed Omar M Makram , Shah Viraj R , Hyma Kunhiraman Harikrishnan , Abi Farraj Sami , Nain Priyanshu , Stabellini Nickolas , Al-Kindi Sadeer , Swami Umang , Ciuro Jordan Alana , Parikh Jigarkumar R. , Esdaille Ashanda R , Klaassen Zachary , Terris Martha K , Cullen Jennifer , Weintraub Neal L , Agarwal Neeraj , Guha Avirup 
Published: February 2025

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Background:
Socioeconomic position (SEP) is a key social determinant of health (SDOH) associated with disparities in cancer care and cardiovascular (CV) outcomes in patients with prostate cancer (PC). Understanding the impact of SEP on cardiovascular health is critical for addressing inequities in PC CV outcomes.
Methods:
We conducted a retrospective cohort study on the SEER-Medicare database. Multiple CV outcomes were assessed in patients ≥65 years of age with no prior CV disease and with localized or advanced PC. SEP was defined using the census-tract level Yost index where those living in first and second quintiles were considered as living in low SEP areas. A competing risk analysis using univariable and multivariable Fine-Gray Models was used for CV events (CVE), CV mortality (CVm) and PC specific mortality (PCsm). CVEs included myocardial infarction, heart failure, atrial fibrillation, ischemic stroke, and peripheral artery disease. All-cause mortality was assessed using Cox proportional hazard (PH) models. All models were adjusted for age, race, marital status, education level, PC grade, PC TNM stage, diabetes, hypertension, hyperlipidemia, chronic kidney disease, and receiving chemotherapy. A sub-group analysis was further conducted in patients who self-identified as non-Hispanic Black (NHB).
Results:
We included 150,647 patients of whom 102,271 had high SEP and 48,376 had low SEP. Patients with low SEP have shown higher associated risks of CVm (subdistribution hazard ratio [sHR] 1.25, 95% CI 1.19-1.32, p<0.001), PCsm (sHR: 1.20, 95% CI 1.14-1.26, p<0.001), CVE (sHR 1.07, 95% CI 1.04-1.09, p<0.001), and all-cause mortality (adjusted HR 1.17, 95% CI 1.14-1.20, p<0.001) when compared to patients with high SEP. Similarly, in the NHB subgroup analysis, patients with low SEP showed an increase of 11% in CVE, 37% in CVm, and 21% in PCsm and 20% all-cause mortality (Table).
Conclusions:
Adverse SEP, as a proxy for SDOH, plays an important role in patients with localized or metastatic PC by increasing associated risks for adverse cardiovascular and survival outcomes by up to 25% in the overall population and 37% in NHB individuals.

Survival analysis using Fine-Gray analysis (competing risk models) and Cox PH regression for the various cardiovascular outcomes using the fully adjusted model.

Overall (n=150,647)
NHB (n=15,474)

CVE (Competing risk = All-cause mortality)sHR (95% CI, p-value)
1.07 (1.04-1.09, p<0.001)
1.11 (1.03-1.20, p=0.007)

CVm (Competing risk = All-cause mortality except CVD mortality)sHR (95% CI, p-value)
1.25 (1.19-1.32, p<0.001)
1.37 (1.15-1.64, p<0.001)

PCsm (Competing risk = All-cause mortality except PCsm)sHR (95% CI, p-value)
1.20 (1.14-1.26, p<0.001)
1.21 (1.04-1.41, p=0.016)

All-cause mortality (Cox)aHR (95% CI, p-value)
1.17 (1.14-1.20, p<0.001)
1.20 (1.08-1.35, p=0.001)