County-level educational attainment and long-term outcomes in older men with prostate cancer: A SEER-Medicare 2009–2017 study.

327 Background: Educational attainment shapes access, treatment, and survivorship in prostate cancer (PC), yet community-level effects remain underexplored. We tested whether residence in low-education counties is associated with prostate cancer-specific mortality (PCSM) and related outcomes in older men with PC. Methods: We analyzed SEER-Medicare (2009-2017) including men aged ≥66 years with incident PC. Low education was defined as counties where >15% of adults lack a high-school diploma. Outcomes were PCSM (primary), cardiovascular events (CVE), cardiovascular mortality (CVm), and all-cause mortality (ACM). Fine-Gray competing-risk and Cox models adjusted for demographics, comorbidities, stage/grade, and treatments. Prespecified subgroup analyses were conducted in non-Hispanic Black (NHB) and urban residents. Results: Median follow-up ranged 3.3-4.5 years among 109,724 complete cases of men (85,516 in high-education and 32,210 in low-education counties). Residence in low-education counties was associated with a higher but not statistically significant risk of PCSM (subdistribution hazard ratio [sHR] 1.06; 95% CI 0.95-1.19; p=0.29). In contrast, low-education residence was associated with higher risks of CVE (sHR 1.04; 95% CI 1.01-1.06; p=0.002), CVm (sHR 1.18; 95% CI 1.12-1.25; p<0.001), and ACM (adjusted HR 1.08; 95% CI 1.05-1.11; p<0.001). Similar trends were observed in NHB and urban populations. Conclusions: Living in counties with lower educational attainment was independently associated with higher cardiovascular and overall mortality after PC diagnosis, with a consistent directional trend toward increased PCSM. Community-level education is a structural determinant of survivorship and a practical target for geospatial outreach to improve outcomes. Association of county level educational attainment with mortality and cardiovascular outcomes across overall, NHB, and urban subgroups. Outcome (Model) Overall (aHR/sHR [95% CI], p) NHB (aHR/sHR [95% CI], p) Urban (aHR/sHR [95% CI], p) PCSM (Fine-Gray) 1.06 (0.95–1.19, p=0.29) 1.08 (0.95–1.23, p=0.25) 1.12 (0.90–1.41, p=0.32) CVE (Fine-Gray) 1.04 (1.01–1.06, p=0.002) 0.98 (0.92–1.05, p=0.53) 1.02 (1.00–1.04, p=0.10) CVm (Fine-Gray) 1.18 (1.12–1.25, p<0.001) 1.08 (0.92–1.27, p=0.36) 1.17 (1.10–1.25, p<0.001) ACM (Cox) 1.08 (1.05–1.11, p<0.001) 1.11 (1.02–1.20, p=0.02) 1.05 (1.02–1.09, p<0.001) Sample sizes: Overall N = 109,724; NHB N = 11,726; Urban N = 93,318. Fine-Gray models account for competing risk of death, and Cox proportional hazards models were used for all-cause mortality. Models adjusted for age, race, marital status, socioeconomic status, rurality, prostate cancer stage and grade, diabetes, hypertension, hyperlipidemia, chronic kidney disease, surgery, radiation, chemotherapy, and prior cardiovascular events.