Abstract Introduction: Disparities in the top two causes of death (COD), cardiovascular disease (CVD) and cancer, are the underlying drivers of higher mortality rates in rural vs. urban populations. Individually, both rates are disproportionately highest in the Southeastern U.S. and are widening among early to middle-aged adults. The extent of rural-urban disparities from the intersection of CVD and cancer, known as cardio-oncology, is unknown. This is relevant as CVD is a leading cause of morbidity and mortality among adult-onset cancer survivors. We aim to compare state-level cardio-oncology mortality rates by rurality among adults aged 25-64 years two ways: CVD as a contributing COD to cancer in the general population and CVD as the underlying COD among cancer cases from Surveillance Epidemiology End Results (SEER) registries. Methods: Age-adjusted mortality rates (AAMR) were calculated from cancer deaths with CVD as the contributing COD (part of chain of events leading to death) among the total general population in the most recent 10-year data (2014-2023) from CDC WONDER - AS1 Wide-ranging ONline Data for Epidemiologic Research developed by Centers for Disease Control and Prevention. Age-adjusted incidence-based CVD mortality rates were calculated using the most recent 10-year data (2013-2022) from SEER 21 registries. Rural vs. urban rate ratios (RR) and 95% confidence intervals (CI) were calculated by state and further stratified by micropolitan/non-core rural areas and stage at diagnosis. Results: A total of 337,561 cancer deaths with CVD were identified between 2014-2023AS2. Compared to urban areas, cardio-oncology mortality in rural areas was higher than in urban areas for 40 states (RR=1.10-2.18) and lower for 6 states (RR=0.78-0.91). Rates in rural non-core areas were highest for 22 states, followed by micropolitan (n=10), and urban areas (n=6). The highest RR for rural vs. urban cardio-oncology mortality disparities in the general population were concentrated in several Southeast and Southwest states. Among cancer cases, CVD accounted for 5.3% of all deaths between 2013-2022. The RR for 14 SEER registries were calculated, of which 9 had higher rural CVD mortality rates than urban areas for stage 3 (RR=1.33-3.00), followed by 8 for stage 1 and 2 (RR=1.04-1.54), and 7 for stage 4 (RR=1.08-1.50). Three Southeastern registries (KY, LA, and Greater GA) were found to have higher rural CVD rates for each cancer stage compared to their urban counterparts. Conclusion: Whether CVD is listed as a contributing COD or underlying COD among cancer cases, adults ages 25-64 years residing in rural areas suffer disproportionately from higher rates of cardio-oncology mortality than urban areas using the most recent 10-year data. The magnitude and geographic distribution vary based on the degree of rurality and stage of cancer. A better understanding of CVD before and after cancer diagnosis is warranted to tailor primary and secondary prevention efforts. Citation Format: Stephanie D. Boone, Katherine L. Boudreau, Stephie A. Abraham, Kathy B. Baumgartner, Richard N. Baumgartner. State-level rural-urban disparities in cardio-oncology mortality among early to middle-aged adults 25-64 years in the US abstract. In: Proceedings of the 18th AACR Conference on the Science of Cancer Health Disparities; 2025 Sep 18-21; Baltimore, MD. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2025;34(9 Suppl):Abstract nr B129.
Boone et al. (Thu,) studied this question.