Rurality Status and Cardiovascular Events/Survival in Older Men With Prostate Cancer

Abstract

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.