Abstract
BACKGROUND: Breast cancer (BC) is the most frequently diagnosed cancer among women in the United States. Cardiovascular disease (CVD) is a major noncancer cause of death among BC survivors. Although greenspace is linked to better CVD and BC-related outcomes, its effect on BC survival is unknown. OBJECTIVES: This study investigates the association between urban greenspace and survival among older BC survivors in the United States and examines regional differences. METHODS: Data from the 2010 to 2017 Surveillance, Epidemiology, and End Results-Medicare BC cohort was used. Women aged 66+ with invasive BC, enrolled in Medicare (Parts A and B) for 12 months prediagnosis and with known tract-level greenspace data (N = 86,300) were included. Greenspace was measured as census tract percent tree canopy quartiles. Survival outcomes included all-cause mortality (ACM), BC-specific mortality (BCSM), and CVD-specific mortality (CVDSM), with censoring by December 31, 2018. Covariates included age, comorbidity, race/ethnicity, Medicaid eligibility, tumor stage and subtype, neighborhood social vulnerability, and population density. RESULTS: Of 86,300 women, 22,541 (26.1%) died during the follow-up, 9,012 (40.6%) and 4,195 (18.9%) died from BC and CVD, respectively. Greater percent tree canopy was associated with lower ACM (HR: 0.90; 95% CI: 0.86-0.95) and BCSM (cause-specific HR: 0.90; 95% CI: 0.82-0.98). Regional variations were observed, with greenspace linked to lower ACM in California, New Jersey, and Michigan, and lower BCSM and CVDSM in California and New Jersey. Washington, Louisiana, and Georgia showed nonsignificant or inconsistent results. CONCLUSIONS: This study highlights the importance of investigating the relationship between greenspace and cardiooncology-related outcomes across regions, underscoring the need for more place-specific research to guide targeted interventions to improve survival outcomes.