Socioeconomic, Lifestyle, and Clinical Factors Associated with Cardiovascular Events in the U.S. Cancer Population

Abstract

Background: Cardiovascular disease (CVD) is a leading cause of mortality among cancer survivors, yet the contributions of socioeconomic, lifestyle, and clinical factors to CVD remain unexplored. Objective: This study was aimed at examining associations between these factors and prevalent CVD in adults with prior cancer and comparing them with those in a matched non-cancer cohort. Methods: We analyzed 97,648 adults from the National Health and Nutrition Examination Survey. Associations of socioeconomic, lifestyle, and clinical factors with a composite endpoint of five self-reported cardiovascular events were assessed with multivariable logistic regression. Interaction analyses assessed differences by cancer status, and sensitivity analyses examined individual cardiovascular outcomes. Results: We included 5584 cancer survivors and 9933 matched participants without cancer. Age, sex, unemployment, low income, current smoking, obesity, diabetes, hypertension, and hypercholesterolemia were associated with elevated odds of CVD prevalence in both groups. Among only cancer survivors, an absence of private insurance, or the presence of food insecurity or low educational attainment, was also independently associated with CVD prevalence. Sensitivity analyses indicated broadly consistent results across individual outcomes. Conclusions: Socioeconomic, lifestyle, and clinical factors were associated with prevalent CVD among cancer survivors, with socioeconomic disadvantage contributing to disparities in CVD burden. Because the outcomes were self-reported, and the study was cross-sectional, the findings should be interpreted as associative rather than causal or predictive.

Keywords

cancer survivorship / cardiovascular disease / socioeconomic determinants / lifestyle factors / prevalent cardiovascular disease

^{Data Availability Statement Ethics Statement Acknowledgements Funding Conflicts of Interest Author Contributions}

References

[1] American Cancer Society. Cancer treatment & survivorship facts & figures 2022-2024. Atlanta: American Cancer Society. 2022

[2] Lipshultz SE, Adams MJ, Colan SD, Constine LS, Herman EH, Hsu DT, et al.. Long-term cardiovascular toxicity in children, adolescents, and young adults who receive cancer therapy: pathophysiology, course, monitoring, management, prevention, and research directions: a scientific statement from the American Heart Association. Circulation. 2013. Vol. 128(17):1927-95

[3] Zamorano JL, Lancellotti P, Rodriguez Muñoz D, Aboyans V, Asteggiano R, Galderisi M, et al.. 2016 ESC Position Paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC Committee for Practice Guidelines: The Task Force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016. Vol. 37(36):2768-801

[4] Guo X, Jiang M, Tao Z, Dai H, Wu C, Wang Y, et al.. 5-Oxoproline prevents doxorubicin-induced cardiotoxicity and tumor growth. Redox Biol. 2025. Vol. 85:103753

[5] Zullig LL, Sung AD, Khouri MG, Jazowski S, Shah NP, Sitlinger A, et al.. Cardiometabolic comorbidities in cancer survivors: JACC: CardioOncology state-of-the-art review. JACC CardioOncol. 2022. Vol. 4(2):149-65

[6] Chow EJ, Chen Y, Armstrong GT, Baldwin LM, Cai CR, Gibson TM, et al.. (2022). Underdiagnosis and undertreatment of modifiable cardiovascular risk factors among survivors of childhood cancer. J Am Heart Assoc. 2022. Vol. 11(12):e024735

[7] Strongman H, Gadd S, Matthews A, Mansfield KE, Stanway S, Lyon AR, et al.. Medium and long-term risks of specific cardiovascular diseases in survivors of 20 adult cancers: a population-based cohort study using multiple linked UK electronic health records databases. Lancet. 2019. Vol. 394(10203):1041-54

[8] Zhu C, Shi T, Jiang C, Liu B, Baldassarre LA, Zarich S. Racial and ethnic disparities in all-cause and cardiovascular mortality among cancer patients in the U.S. JACC CardioOncol. 2023. Vol. 5(1):55-66

[9] U.S. Department of Health and Human Services. Healthy People 2030:Social Determinants of Health[Internet]. Washington, DC: Office of Disease Prevention and Health Promotion. 2026 cited 2026 May 15

[10] United States Census Bureau. How the Census Bureau measures poverty. Washington, DC: U.S. Census Bureau. cited 2026 May 15

[11] Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to measuring household food security, Revised 2000. USDA, Department of Agriculture, Food and Nutrition Service. 2000

[12] Carlson SJ, Andrews MS, Bickel GW. Measuring food insecurity and hunger in the United States: development of a national benchmark measure and prevalence estimates. J Nutr. 1999. Vol. 129 2S Suppl:510S-516S

[13] Centers for Disease Control and Prevention.National health and nutrition examination survey. [Internet]Atlanta, GA: National Center for Health Statistics. cited 2026 May 15

[14] Armstrong T, Bull F. Development of the World Health Organization Global Physical Activity Questionnaire (GPAQ). J Public Health. 2006. Vol. 14:66-70

[15] Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, Donato KA, et al.. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2014. Vol. 129 25 Suppl 2:S102-38

[16] Stekhoven DJ, Bühlmann P. MissForest-non-parametric missing value imputation for mixed-type data. Bioinformatics. 2012. Vol. 28(1):112-8

[17] Bhaskaran K, Smeeth L. What is the difference between missing completely at random and missing at random? Int J Epidemiol. 2014. Vol. 43(4):1336-1339

[18] He J, Bundy JD, Geng S, Tian L, He H, Li X, et al..Social, behavioral, and metabolic risk factors and racial disparities in cardiovascular disease mortality in U.S. adults : an observational study. Ann Intern Med. 2023. Vol. 176(9):1200-8

[19] Satti DI, Chan JSK, Dee EC, Lee YHA, Wai AKC, Dani SS, et al.. (2024). Associations between social determinants of health and cardiovascular health of U.S. adult cancer survivors. JACC CardioOncol. 2024. Vol. 6(3):439-50

[20] Sheskin DJ. Handbook of parametric and nonparametric statistical procedures: Third edition (3rd ed). Boca Raton: Chapman and Hall/CRC. 2004

[21] Zhang YB, Chen C, Pan XF, Guo J, Li Y, Franco OH, et al.. Associations of healthy lifestyle and socioeconomic status with mortality and incident cardiovascular disease: two prospective cohort studies. BMJ. 2021. Vol. 373:n604

[22] Minhas AMK, Jain V, Li M, Ariss RW, Fudim M, Michos ED, et al.. Family income and cardiovascular disease risk in American adults. Sci Rep. 2023. Vol. 13(1):279

[23] Rosengren A, Smyth A, Rangarajan S, Ramasundarahettige C, Bangdiwala SI, AlHabib KF, et al.. Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries: the Prospective Urban Rural Epidemiologic (PURE) study. Lancet Glob Health. 2019. Vol. 7(6):e748-60

[24] Albano JD, Ward E, Jemal A, Anderson R, Cokkinides VE, Murray T, et al.. Cancer mortality in the United States by education level and race. J Natl Cancer Inst. 2007. Vol. 99(18):1384-94

[25] Noyd DH, Liu Q, Yasui Y, Chow EJ, Bhatia S, Nathan PC, et al.. Cardiovascular risk factor disparities in adult survivors of childhood cancer compared with the general population. JACC CardioOncol. 2023. Vol. 5(4):489-500

[26] Ogland-Hand C, Ciesielski TH, Daunov K, Bean MK, Nock NL.Food insecurity and nutritional challenges in adolescent and young adult cancer survivors in the U.S. A.: a narrative review and call to action. Nutrients. 2023. Vol. 15(7):1731

[27] Shi T, Jiang C, Zhu C, Wu F, Fotjhadi I, Zarich S. Insurance disparity in cardiovascular mortality among non-elderly cancer survivors. Cardiooncology. 2021. Vol. 7(1):11

[28] Xu L, Wang X, Pan X, Wang X, Wang Q, Wu B, et al.. Education level as a predictor of survival in patients with multiple myeloma. BMC Cancer. 2020. Vol. 20:737

[29] Kocaöz S, Özçelik H, Talas MS, Akkaya F, Özkul F, Kurtuluş A, et al.. The effect of education on the early diagnosis of breast and cervix cancer on the women’s attitudes and behaviors regarding participating in screening programs. J Cancer Educ. 2018. Vol. 33(4):821-32

[30] Liu Y, Zhang J, Huang R, Feng WL, Kong YN, Xu F, et al.. Influence of occupation and education level on breast cancer stage at diagnosis, and treatment options in China: a nationwide, multicenter 10-year epidemiological study. Medicine (Baltimore). 2017. Vol. 96(15):e6641

[31] Walker GV, Grant SR, Guadagnolo BA, Hoffman KE, Smith BD, Koshy M, et al.. Disparities in stage at diagnosis, treatment, and survival in nonelderly adult patients with cancer according to insurance status. J Clin Oncol. 2014. Vol. 32(28):3118-25

[32] Hoffman KE, McCarthy EP, Recklitis CJ, Ng AK. Psychological distress in long-term survivors of adult-onset cancer: results from a national survey. Arch Intern Med. 2009. Vol. 169(14):1274-81

[33] Mackenbach JP, Cavelaars AE, Kunst AE, Groenhof F. Socioeconomic inequalities in cardiovascular disease mortality;an international study. Eur Heart J. 2000. Vol. 21(14):1141-51

[34] Brandt EJ, Mozaffarian D, Leung CW, Berkowitz SA, Murthy VL. Diet and food and nutrition insecurity and cardiometabolic disease. Circ Res. 2023. Vol. 132(12):1692-706

[35] Thorndike AN, Gardner CD, Kendrick KB, Seligman HK, Yaroch AL, Gomes AV, et al.. Strengthening US Food Policies and Programs to promote equity in nutrition security: a policy statement from the American Heart Association. Circulation. 2022. Vol. 145(24):e1077-93

[36] U.S. Department of Health and Human Services. Heart disease and hispanic Americans. Office of Minority Health.

[37] Henderson SO, Haiman CA, Wilkens LR, Kolonel LN, Wan P, Pike MC. Established risk factors account for most of the racial differences in cardiovascular disease mortality. PLoS One. 2007. Vol. 2(4):e377

[38] Post WS, Watson KE, Hansen S, Folsom AR, Szklo M, Shea S, et al.. Racial and ethnic differences in all-cause and cardiovascular disease mortality: the MESA study. Circulation. 2022. Vol. 146(3):229-39

[39] Sung H, Nisotel L, Sedeta E, Islami F, Jemal A. Racial and ethnic disparities in survival among people with second primary cancer in the US. JAMA Netw Open. 2023. Vol. 6(8):e2327429

[40] Johnson MN. Cardio-oncology and health equity: opportunities for implementation. JACC CardioOncol. 2023. Vol. 5(4):546-50