Social Determinants of Health and Cardiovascular Disease–Related Outcome Disparities Among Breast Cancer Survivors: A Systematic Review

Abstract

Background

Breast cancer is the most commonly diagnosed malignancy worldwide. Breast cancer survivors face an increased risk of cardiovascular disease (CVD), a leading cause of death in this group. Social determinants of health (SDoHs), operationalized as economic, environmental, and psychosocial factors, play an important role in CVD disparities. However, few studies have examined how SDoHs are associated with CVD disparities in this population, and no systematic review has addressed their multilevel influences.

Methods

This systematic review summarizes the current evidence on the relationships between SDoHs at different levels and CVD disparities among breast cancer survivors. Using the 2024 American College of Cardiology/American Heart Association framework, SDoHs were categorized at the individual, interpersonal, or community levels. Studies published in peer‐reviewed journals between January 1, 2010, and November 30, 2025, were identified through searching electronic databases (PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, PsycINFO) and citations.

Results

Of 6550 unique records, 37 articles that addressed the impact of SDoHs on CVD outcomes were selected. Most (n=31) were conducted in the United States and used retrospective designs (n=29). Most (n=30) focused on individual‐level SDoHs such as race, income, or education; 2 on interpersonal‐level SDoHs (ie, psychosocial stress); and 13 on community‐level SDoHs, including neighborhood socioeconomic status and residential area. Black race, lower neighborhood socioeconomic status, and rural residence were associated with a higher incidence of CVD and increased cardiovascular death.

Conclusions

This review highlights the urgent need to address SDoHs and emphasizes the importance of multilevel interventions to reduce CVD disparities among breast cancer survivors.

Clinical Perspective.

What Is New?

• This systematic review is the first to apply the 2024 American Heart Association Social Determinants of Health framework to cardiovascular disease outcomes among female breast cancer survivors, highlighting the predominance of individual‐level factors and limited research on interpersonal and multilevel social determinants of health.

What Are the Clinical Implications?

• This systematic review demonstrates that adverse social determinants of health, particularly Black race, low neighborhood socioeconomic status, and rural residence, are associated with higher cardiovascular disease incidence and death among breast cancer survivors.

• Multilevel studies using standardized measures of individual, interpersonal, and community‐level social determinants of health, along with a causal framework, may promote more equitable health care access and help reduce cardiovascular disease disparities among breast cancer survivors.

Nonstandard Abbreviations and Acronyms

SDoH

social determinant of health

SEER

Surveillance, Epidemiology, and End Results

Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer‐related death among women worldwide. In 2020, 2.26 million new cases and 685 000 deaths were reported worldwide, which represented 1 in 4 new diagnoses and 1 in 6 cancer‐related deaths among women. ¹ As survival rates improve due to advances in treatment, cardiovascular diseases (CVDs) have emerged as a major health concern for breast cancer survivors. Shared risk factors between CVD and breast cancer, including older age, smoking, poor diet, obesity, and diabetes, ² along with cardiotoxic effects of certain breast cancer treatments, ³ contribute to an elevated CVD burden. For breast cancer survivors, CVD is the leading noncancer cause of death, accounting for nearly a third of non–breast cancer deaths among survivors aged ≥50 years. ⁴ Despite ongoing efforts to mitigate traditional CVD risk factors through preventive care, CVD risk persists and is expected to increase. ⁵

Social determinants of health (SDoHs), including economic, social, environmental, and psychosocial factors at the individual, interpersonal, and community levels, have been recognized as long‐standing, fundamental drivers of CVD. As upstream determinants, they act along causal pathways that influence the development and progression of traditional cardiovascular risk factors such as hypertension, diabetes, and smoking, thereby worsening CVD‐related death and contributing to disparities in CVD outcomes. ⁶ , ⁷ As a result, recent studies have increasingly focused on the impact of SDoHs to reduce CVD risk and improve cardiovascular health. ⁸ For example, low individual socioeconomic status (SES), ⁹ including limited income or education, chronic exposures to social isolation and discrimination, ¹⁰ and neighborhood violence ¹¹ have all been linked to increased CVD risk through biologic mechanisms such as chronic inflammation, ¹⁰ stress hormone dysregulation, ⁹ and accelerated cellular aging. ¹¹ While 1 prior systematic review addressed disparities in CVD‐related outcomes among cancer survivors, that review primarily focused on the general cancer survivor population, was limited to US‐based studies, and did not fully consider the multilevel impact of SDoHs on CVD outcomes. ¹² Despite growing evidence linking SDoHs to cardiovascular outcomes, these studies have not been systematically synthesized to assess how different levels of SDoHs associate with CVD‐related disparities, specifically in this population, and from a global perspective. This gap is critical due to the increasing international burden of both breast cancer and CVD, along with the disproportionate impact of structural and social inequities on CVD outcomes in breast cancer survivors.

To address this need, our review adopted the 2024 American College of Cardiology/American Heart Association framework for SDoHs, ¹³ which provides a multilevel structure encompassing individual, interpersonal, and community‐level determinants essential for capturing the complex pathways through which SDoHs are associated with CVD outcomes. Individual‐level SDoHs include race and ethnicity, education, income, employment, and insurance status; interpersonal‐level SDoHs include social connection, discrimination, and psychosocial stress; and community‐level SDoHs include racial segregation, environmental exposures, access to care, violence, and area‐level socioeconomic conditions. Using this framework, we conducted a systematic review of peer‐reviewed, quantitative studies published between 2010 and 2025 that examined the associations between SDoHs and CVD‐related outcomes among breast cancer survivors. Our objectives were to describe how SDoHs have been measured and applied in CVD studies, to summarize the evidence on the association between various SDoH factors and CVD outcomes, and to assess whether SDoHs are related to disparities in CVD outcomes among breast cancer survivors.

METHODS

Institutional review board approval was not required because this systematic review used only publicly available, previously published data. The authors declare that all supporting data are available in the article and its online Supplemental Material.

Search Strategy and Selection Criteria

The study was not registered with the International Prospective Register of Systematic Reviews, but a review protocol was developed before conducting the systematic review. Following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines, ¹⁴ we reviewed English‐language articles published in peer‐reviewed journals from January 2010 to November 2025 that addressed SDoHs in relation to CVD‐related outcomes among female breast cancer survivors. The literature search was limited to studies published from 2010 onward to reflect more recent trends in the literature (over the past 15 years) and align with the modern conceptualization of SDoHs as put forward in the 2010 World Health Organization's Commission on the Social Determinants of Health. ¹⁵ The search retrieved observational and interventional studies that focused on female patients with breast cancer and had the primary or secondary objective of examining or addressing SDoHs related to adverse CVD‐related outcomes. We performed systematic literature searches using the following databases: PubMed (US National Library of Medicine), Embase (Elsevier), Cumulative Index to Nursing and Allied Health Literature (EBSCO), Web of Science Core Collection (Clarivate Analytics), and PsycINFO (American Psychological Association). A search strategy was developed using keywords, controlled vocabularies (such as Medical Subject Headings or Emtree), and synonyms related to SDoHs, CVD, and CVD‐related outcomes. The literature search was conducted sequentially (an initial search followed by an updated search), and all identified records were combined before duplicate removal and screening. The same eligibility criteria and screening procedures were applied in both searches. The full search strategy is detailed in Table S1.

Article Selection Process

All articles were imported into EndNote version 21, and duplicates were removed. Two reviewers (M.L. and V.D.) independently screened titles and abstracts for eligibility on the basis of the inclusion and exclusion criteria. Following this, full texts of articles eligible for further review were examined in detail. Disagreements were first addressed through discussion between the 2 reviewers. If consensus could not be reached, a third reviewer (H.P.) was consulted for adjudication. All eligible studies from the initial screening were then reviewed for full‐text eligibility. The Population, Intervention/Exposure, Comparison, and Outcomes framework was used to guide the evidence search strategy. ¹⁶

P (Population): Adult female breast cancer survivors (aged ≥18 years) as defined by the National Cancer Institute from the time of clinical diagnosis until the end of life.

I (Intervention)/E (Exposure): The studies included at least 1 SDoH as an intervention/exposure component or as part of the analysis.

C (Comparison): Comparison groups specified in studies, such as non‐Hispanic White women and Hispanic/Latina women, or those of higher SES and those of lower SES.

O (Outcomes): Studies that examined outcomes including CVD‐related death, CVD incidence, or chemotherapy‐related cardiotoxicity.

Eligibility Criteria

The inclusion criteria for the studies were as follows: (1) full‐text, peer‐reviewed journal articles written in English; (2) studies that used a randomized controlled trial, cohort study, or case–control study design; (3) studies that included women aged ≥18 years who were breast cancer survivors, as defined by the National Cancer Institute; (4) studies that were published between January 2010 and November 2025; (5) studies that reported on CVD‐related outcomes including cardiovascular death, CVD incidence, or cardiotoxicity; and (6) studies that examined at least 1 of the SDoHs as an exposure, as described below. Exclusion criteria included (1) non–peer‐reviewed articles, abstracts, editorials, protocols, case reports, conference proceedings, preprints, and other review articles; (2) studies that did not focus on breast cancer survivors or that included women with metastatic cancer; and (3) studies that did not examine SDoHs or that did not report on CVD‐related outcomes.

SDoH Framework

We used the American College of Cardiology/American Heart Association SDoH framework described earlier to guide data extraction and synthesis of included studies. ¹³ To operationalize SDoHs in this review, we developed a comprehensive search strategy that included keywords and subject headings related to specific SDoH domains across the 3 levels (Table S1).

CVD Outcomes Definitions

For this review, CVD outcomes were defined as follows: (1) CVD, including coronary heart disease (eg, ischemic heart disease, myocardial infarction), cerebrovascular disease (eg, stroke), heart failure, and aortic disease ¹⁷ ; (2) CVD incidence, defined as the occurrence of clinical CVD events during breast cancer survivorship; (3) CVD‐related death, defined as death from cardiovascular causes; and (4) cardiotoxicity, defined as chemotherapy‐related cardiovascular injury, indicated by a decline in left ventricular ejection fraction of ≥10% to <50%, or the presence of heart failure symptoms regardless of left ventricular ejection fraction according to international guidelines. ¹⁸

Data Extraction

After selecting the final studies from the full‐text review, two reviewers independently extracted the data (M.L. and V.D.). The authors cross‐checked all extracted data, and discrepancies were resolved through consensus. We systematically extracted the following information from each study: first author, publication year, study design, and study measures (SDoHs, CVD outcomes); CVD disparities explored, including at least 1 SDoH measure; and key findings related to CVD outcomes, including metrics such as CVD death, CVD incidence, and chemotherapy‐induced cardiotoxicity. A meta‐analysis was not performed because of substantial heterogeneity in how studies defined and measured SDoH and CVD outcomes, as well as differences in analytic methods and covariate adjustment. These differences limited the comparability of effect measures and made quantitative synthesis infeasible. In addition, several studies used overlapping data sources (eg, SEER [Surveillance, Epidemiology, and End Results]–linked data sets), potentially violating the independence assumption required for meta‐analysis and leading to biased pooled estimates. ¹⁹ , ²⁰ Therefore, we summarized findings using a narrative synthesis approach.

Quality Assessment

The quality of the studies was evaluated using the Mixed Methods Appraisal Tool, which includes fixed‐response items based on study design. ²¹ This tool was applied to assess the quality of quantitative studies and nonrandomized controlled trials. Each study was assessed with 2 screening questions and 5 design‐specific criteria. Two reviewers (M.L. and V.D.) assessed each article to determine its quality and worked together to resolve any discrepancies until they reached a consensus.

RESULTS

Study Selection

Figure 1 shows a Preferred Reporting Items for Systematic Reviews and Meta‐Analyses flow diagram illustrating the article selection process included in the systematic review. The initial search strategy identified 7480 records from 5 databases (PubMed, n=1193; Embase, n=1893; Cumulative Index to Nursing and Allied Health Literature, n=1483; Web of Science, n=2903; PsycINFO, n=3) and citation searching (n=31). After removing 961 duplicates, 6550 titles and abstracts were screened, of which 5778 were excluded. Of the 772 full‐text articles assessed for eligibility, 735 studies were excluded on the basis of the eligibility criteria. Thus, a total of 37 studies were identified and were included in the final systematic review.

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta‐Analysis flow diagram illustrating the selection process of studies.

CINAHL indicates Cumulative Index to Nursing and Allied Health Literature; CVD, cardiovascular disease; and SDoHs, social determinants of health.

Study Characteristics

Of the 37 studies included, 28 were published after 2021 (Table 1). Most (n=29) were retrospective cohort studies, 4 were prospective cohort studies, 1 was a mixed (prospective and retrospective) cohort study, and 2 were case–cohort studies. Most (n=31) were conducted in the United States. Thirty‐seven studies examined various measures of SDoHs. Most studies (n=30) focused on individual‐level SDoH factors, such as race, income, or education, while 13 studies targeted community‐level SDoH factors, including community‐level SES, access to health care services, or the built environment. Two studies addressed interpersonal‐level SDoH factors, such as social support and psychosocial stress. The included studies assessed CVD death (n=21), CVD incidence (n=13), or cardiotoxicity related to cancer therapy (n=6). Among the 37 studies, the mean (or median) age among those that reported this (n=30) ranged from 50 to 85 years. Across 29 US‐based studies reporting race and ethnicity, non‐Hispanic White participants consistently represented the largest proportion of study samples, accounting for about 79% of participants when weighted by study size. Additionally, 25 of the 37 studies focused on racial and ethnic disparities in CVD‐related outcomes. Additional details on the characteristics of the studies included in this review are provided in Table 2.

Table 1.

Overall Characteristics of Included Studies in the Review (n=37)

Characteristics	Studies, n (%) (n=37)
Publication year
2010–2015	2 (5.4)
2016–2020	7 (18.9)
2021–2025	28 (75.7)
Study site
United States	31 (83.8)
England	1 (2.7)
Netherlands	1 (2.7)
Denmark	1 (2.7)
Israel	1 (2.7)
Singapore	1 (2.7)
Multinational	1 (2.7)
Study design
Secondary analysis of randomized controlled trial	1 (2.7)
Observational	34 (91.9)
Cross‐sectional	0 (0)
Prospective cohort	4 (11.8)
Retrospective cohort	29 (85.3)
Mixed cohort	1 (2.9)
Case‐cohort	2 (5.4)
Case–control	0 (0)

SDoH measures	Studies, n (%) (n=37)
Single level	29 (78.4)
Individual level	22 (75.9)
Interpersonal level	2 (6.9)
Community level	5 (17.2)
Mulilevel	8 (21.6)
Individual level+community level	8 (100)

CVD outcomes measures	Studies, n* (n=40)
CVD death	21
CVD incidence	13
Cardiotoxicity	6

Percentages may not equal 100% because of rounding.

CVD indicates cardiovascular disease; and SDoH, social determinant of health.

^*Some studies reported multiple CVD‐related outcomes.

Table 2.

Summary of Characteristics of Included Studies in the Review (n=37)

No.	Author/year	Region/source/study period	Study design	Study population	Sample size	Age, y, mean	Racial and ethnic background	SDoH measures
								Individual level	Interpersonal level	Community level
1	Al‐Sadawi et al 2021 33	United States, Memorial Sloan Kettering Cancer Center, 2004–2013	Retrospective cohort study	Women with HER2‐positive breast cancer with trastuzumab‐based therapy	1399	51	76% White 12% Black 12% Others	Race Household income Health insurance	NA	Community‐level education (percentage of people in patient's zip code with less than a high‐school degree)
2	Appiah et al 2021 57	United States, SEER registry, 2000–2016	Retrospective cohort study	Women aged >20 y who were diagnosed with breast cancer	818 517	60.5	70% White 10.3% Black 11.0% Hispanic	Race Health Insurance Household income Education Employment	NA	Primary care provider density Neighborhood socioeconomic index Residence (rural vs urban)
3	Solanki et al 2016 46	United States, SEER registry, 1991–2011	Retrospective cohort study	Women >20 y who were diagnosed with a first primary invasive, stage I–III breast cancer	506 536	61.2 in NHW, 56.3 in API	91.2% NHW 8.8% API	Ethnicity	NA	NA
4	Litvak et al 2018 43	United States, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, 2005–2015	Retrospective cohort study	Women with HER2‐positive, stage I–III breast cancer who initiated (neo) adjuvant HER2‐targeted therapy	216	52	157 White 59 Black	Race	NA	NA
5	Connor et al 2022 28	United States, Maryland Cancer Registry, 2007–2017	Retrospective cohort study	Women aged ≥18 y who were diagnosed with primary invasive breast cancer as their first cancer	36 088	60.7	25 181 White 10 907 Black	Race	NA	NA
6	Conroy et al 2023 58	United States, Kaiser Permanente Northern California registry, 2006–2013	Prospective cohort study	Women diagnosed with breast cancer	3975	59.4	2623 (66%) NHW 524 (13.2%) Asian 443 (11.1%) Hispanic 297 (7.5%) Black	NA	NA	Neighborhood SES Racial and ethnic composition Urbanization Crime index
7	Troeschel et al 2019 31	United States, SEER database, 1990–2014	Retrospective cohort study	NHB and NHW women aged ≥18 y who were diagnosed with invasive breast cancer	407 587	NHW vs NHB <55: 30.7% vs 43.3% 55–68: 32.4% vs 32.2% >69: 37.0% vs 24.6%	43 562 (10.7%) NHB 364 025 (89.3%) NHW	Race and ethnicity	NA	NA
8	Hashibe et al 2024 56	United States, SEER Medicare linked database, 2000–2020	Retrospective cohort study	Women aged ≥66 y who were diagnosed with a first primary invasive breast cancer between 2000 and 2017	28 487	ANHPI vs NHB 66–75: 58.3% vs 58.3% 76–100+: 41.7% vs 41.7%	7122 ANHPI 21 365 NHW	Race and ethnicity	NA	NA
9	Berkman et al 2014 34	United States, 2010 SEER incidence database	Retrospective cohort study	Women aged ≥40 y with newly diagnosed DCIS from 1978 to 2010	67 514	NA	54 518 White, 6117 Black, 6487 Other, 401 unknown race	Race	NA	NA
10	Tsai et al 2014 36	United States, SEER Medicare database, 198–2007	Retrospective cohort study	Women aged ≥66 y who were newly diagnosed with breast cancer as their first cancer	68 536	72.0	85% White, 8% Black	Race Household income	NA	NA
11	Ho et al 2023 51	United States, SEER‐18 cancer registry, 2001–2018	Retrospective cohort study	Women diagnosed with first, primary localized, or regional stage breast cancer were diagnosed between ages 18 and 84 y, and survived ≥12 mo and received surgery	724 518	18–49 y: 25%, 50–59 y: 26.39%, 60–69 y: 25.73%, 70–84 y: 22.87%	10.40% Hispanic or Latina, 0.41% American Indian or Alaska Native women, 8.17% non‐Hispanic Asian American, Native Hawaiian, or other Pacific Islander women, 10.19% NHB, 70.83% NHW women	NA	NA	County‐level SES Residence (rurality)
12	Raisi‐Estabragh et al 2023 44	United States, Multiple Cause of Death database, 1999–2019	Retrospective cohort study	Women who were diagnosed with breast cancer	NA	NA	NA	Ethnicity	NA	Residence (rurality)
13	Battisti et al 2022 52	England, Public Health England National Cancer Registration Dataset, 2013–2018	Retrospective cohort study	Women aged 25–100 y at breast cancer (stage I–III) diagnosis, those with residency in England	226 516	67.2±12.7	87.7% White, 0.5% Mixed, 3.6% Asian, 2.0% Black	Ethnicity	NA	Income
14	Bostany et al 2024 47	United States, Next Steps Breast Cancer Survivorship Clinic at the University of Alabama at Birmingham, 2017–2023	Mixed cohort study	Patients with breast cancer who completed cardiotoxic therapy underwent echocardiographic screening every 2 y	829	54.2	63.9% NHW, 28.8% NHB	Race	NA	NA
15	Cheng et al 2022 45	United States, Multiethnic Cohort database, 1993–2013	Prospective cohort Study	Women who are diagnosed with breast cancer	3089	≥45	38% Black, 19% White, 12% Asian, 31% Hispanic	Race/ethnicity	NA	Air pollutant Neighborhood SES
16	Deen et al 2018 40	Netherlands, Dutch nationwide register‐based cohort study, 1996–2010	Retrospective cohort study	All women with a first admission for breast cancer between 1996 and 2010	127 714	Dutch: 60.4 y 52.8% Antilleans: 57.0% Indonesians 47.0% Moroccans 52.8% Surinamese 49.5% Turkish	120 809 Dutch 454 Antilleans 3457 Indonesians 919 Moroccans 1351 Surinamese 724 Turkish	Ethnicity	NA	NA
17	Hamood et al 2019 53	Israel, Leumit Health Services, 2002–2012	Case–cohort study	Women who were diagnosed with primary nonmetastatic invasive breast cancer between 2002 and 2012	2165	NA	NA	Education Employment	NA	Access to health care service (outpatient visit)
18	He et al 2023 38	United States, SEER database, 2010–2018	Retrospective cohort study	Patients with pathological diagnosis of breast cancer from 2010 to 2018	399 014	≥60	79.8% White, 13.9% Black	Race Household income	NA	NA
19	Koric et al 2022 24	United States, Utah Cancer Registry, 1997–2009	Case–cohort study	Women aged ≥18 y who were diagnosed with breast cancer	6641	NA	95.5% White, 1.2% Asian, 0.2% Black, 2.8% multiracial, 0.2% Pacific Islander	Education	NA	Residence (rural vs urban)
20	Obeidat et al 2024 22	United States, National Inpatient Sample, 2016–2019	Retrospective cohort study	Female patients aged ≥18 y with a diagnosis of breast cancer	455 328	72.9	78.1% White, 11.7% Black, 5.7% Hispanic, 2.0% API, 0.3% Native American	Race	NA	NA
21	Shi et al 2021 27	United States, SEER database, 2007–2016	Retrospective cohort study	Female patients aged between 18 and 64 y at time of breast cancer diagnosis	343 516	NA	NA	Health insurance (uninsured, Medicaid, non‐Medicaid)	NA	NA
22	Stabellini et al 2024 30	United States, University Hospitals Seidman Cancer Center (Northeast Ohio), 2010–2019	Retrospective cohort study	Female patients aged ≥18 y diagnosed with breast cancer	8328	Median, 65 y	19.4% NHB, 80.6% NHW	NA	Chronic stress (measured by allostatic load, which is a score composed by cardiovascular, metabolic, and immune markers)	NA
23	Stabellini et al 2023 23	United States, University Hospitals Seidman Cancer Center (Northeast Ohio), 2010–2019	Retrospective cohort study	Female patients aged ≥18 y diagnosed with breast cancer	4309	Median, 63 y	81.3% NHW 18.7% NHB	NA	NA	Neighborhood median household income Neighborhood crime index Number of transportation properties in the household Neighborhood burglary index Neighborhood median home values
24	Vaynrub et al 2024 29	United States, Columbia University Irving Medical Center in New York, 2007–2022	Retrospective cohort study	Female patients diagnosed with stage I–III HER‐positive breast cancer and received at least 1 dose of trastuzumab	496	Median, 53 y	36.6% NHW 15.8% NHB 27.8% Hispanic, 19.8% API or other	Race	NA	NA
25	Wang et al 2021 50	United States, SEER database, 2010–2016	Retrospective cohort study	Patients aged ≥18 y with a histologically confirmed diagnosis of primary T1–2N0M0 breast cancer	161 966	9.6% <45 y, 48.4% 45–65, 38.1% 65–85, 3.9% >85	80.7% White 9.7% Black	Race	NA	NA
26	Zhu et al 2023 54	United States, SEER database, 2000–2018	Retrospective cohort study	Female patients aged ≥18 y diagnosed with breast cancer	872 375	NA	NA	Race	NA	NA
27	Gernaat et al 2017 32	Singapore, National University Hospital (1990–2011) and KK Women's and Children's Hospital (2005–2015)	Prospective cohort study	Women with in‐situ or nonmetastasized invasive breast cancer	5868	Median, 52 y	79% Chinese, 12% Malay, 6% Indian, 3% other	Ethnicity	NA	NA
28	Azambuja et al 2020 37	International, pooled analysis of Herceptin Adjuvant (HERA; BIG1–01), National Surgical Adjuvant Breast and Bowel Project B‐31, North Central Cancer Treatment Group 9831	Secondary analysis of randomized controlled trial	HER2‐positive early breast cancer, sequentially to or concomitantly with chemotherapy (anthracycline/taxane based)	7445	7.1% <35, 85.5% 35–64, 7.5% ≥65	International	Ethnicity	NA	NA
29	Matthews et al 2021 25	United States, SEER database, 2004–2013	Retrospective cohort study	Women aged >65 y with an incident stage I–III breast cancer diagnosis	545 670	48.1% 66–75, 39.1% >75–85, 12.8% >85	86.3% White, 7.9% Black, 2.3% Asian, 1.2% Hispanic, 0.2% Native American	Race and ethnicity	NA	NA
30	Wang et al 2024 42	United States, Women's Health Initiative, 1993	Prospective cohort study	Postmenopausal women who were newly diagnosed with invasive breast cancer	9154	50–79	90.4% White, 5.4% Black, 1.9% Asian	NA	Social support, social strain, social stress	NA
31	Yeo et al 2024 55	United States, Centers for Disease Control and Prevention's Wide‐Ranging Online Data for Epidemiologic Research, 1999–2020	Retrospective cohort study	Breast cancer patients aged ≥25 y	74 773	NA	84.0% NHW, 10.6% NHB, 3.3% Hispanic or Latina	Race and ethnicity	NA	Residence (rural vs urban)
32	Bikomeye et al 2025 26	United States, SEER database, 2010–2017	Retrospective cohort study	Patients with breast cancer aged 60–99 y	86 300	56.1% ≤75, 53.9% >75	82.0% NHW, 7.8% NHB, 6.0% Hispanic	NA	NA	Greenspace (census tract percent tree canopy)
33	Bikomeye et al 2025 41	United StatesUSA, Froedtert Hospital data, 2009–2018	Retrospective cohort study	Women who were diagnosed with primary breast cancer and treated with anthracyclines or anti‐HER2 therapy	849	52.3±11.9 y	78.0% NHW, 16.4% NHB, 3.2% Hispanic	NA	NA	Greenspace (census tract percent tree canopy)
34	Kjaer et al 2025 35	Denmark, SEQUEL (Inequality in SEQUELae After Cancer) cohort, 1997–2018	Retrospective cohort study	Women who were diagnosed with a primary breast cancer aged ≥40 y	42 339	Median, 63.5 y	NA	Education duration (long: >12 y, medium: 8–12 y, short: mandatary education up to 7 y)	NA	NA
35	Le et al 2025 39	United States, SEER database, 2007–2019	Retrospective cohort study	Women aged ≥66 y with a new primary diagnosis of breast cancer who received anthracyclines within 1 y after diagnosis	5771	Median, 69.0 y	90.2% White, 9.8% Black	Race	NA	NA
36	Luo et al 2025 48	United States, SEER database, 2000–2019	Retrospective cohort study	Women aged ≥18 y with a primary diagnosis of breast cancer	655 552	65.3% ≤65, 34.7% >65	76.1% White, 16.9% Black	Race, marital status, household income	NA	NA
37	Wadden et al 2025 49	United States, WHI (Women's Health Initiative) Extension Study II	Retrospective cohort study	Postmenopausal women aged 50–79 y with a primary diagnosis of breast cancer	10 954	72.3±8.3 y	89.7% White, 6.1% Black, 2.7% Hispanic/Latina	Insurance, household income	NA	Residence (rural vs urban)

ANHPI indicates Asian, Native Hawaiian, and Pacific Islander; API, Asian or Pacific Islander; DCIS, ductal carcinoma in situ; HER2, human epidermal growth factor receptor 2; NA, not available; NHB, non‐Hispanic Black; NHW, non‐Hispanic White; SEER, Surveillance, Epidemiology and End Results; SDoHs, social determinants of health; and SES, socioeconomic statusa.

Characterization of SDoHs

The frequencies of SDoH measures examined as exposures of interest in the studies are illustrated in Table 1 and Figure 2. Of the 37 studies, 30 focused on the relationship between individual‐level SDoHs and CVD‐related outcomes, while 13 focused on community‐level SDoHs and CVD outcomes. Only 2 studies addressed interpersonal‐level SDoHs. Among individual‐level SDoH measures, race and ethnicity were the most commonly examined exposures (n=25), followed by household income (n=6), education (n=4), health insurance (n=4), and employment (n=2). At the interpersonal level, 2 studies investigated psychosocial stress as an exposure of interest. In terms of community‐level SDoHs, residential area (rurality) was the most frequently studied (n=7), followed by neighborhood‐level SES (n=4); community‐level education, income, and employment (n=3); built environment (n=3); access to health care services (n=2); and community‐level crime rate (n=2). Most studies (n=29) focused only on single‐level SDoHs, while 8 studies investigated multilevel SDoHs, combining individual and community‐level SDoH elements.

Figure 2. SDoH levels and elements addressed in the included studies in the review (number and percentage of included studies).

SDoH indicates social determinant of health; and SES, socioeconomic status.

Association Between SDoHs and CVD‐Related Outcomes

Table 3 and Figure 3 summarize the key findings of the 37 selected articles about the relationship between each level of SDoH elements and CVD‐related outcomes among breast cancer survivors.

Table 3.

Association Between SDoHs and CVD‐Related Outcomes of Included Studies in the Review (n=37)

No.	Author/year	Cardiovascular disease‐related outcomes			Conclusions
		CVD death	Incidence/prevalence of CVD	Cardiotoxicity related to chemotherapy
1	Al‐Sadawi et al 2021 33	NA	NA	Race and ethnicity: OR (Black vs White), 1.92 (95% CI, 1.23–2.98)	Black women had 1.92 times higher odds of developing cardiotoxicity than White women.
		NA	NA	Household income: OR (low vs medium/high), 1.19 (95% CI, 0.68–2.10)	Women with low income have 19% higher odds of having cardiotoxicity compared with those with medium/high income, but not statistically significant.
		NA	NA	Health insurance: OR (Medicare vs Private), 0.93 (95% CI, 0.61–1.44) OR (Medicaid vs Private), 0.70 (95% CI, 0.38–1.31)	Women who have Medicare have 7% lower odds of experiencing cardiotoxicity compared with those with private insurance but not statistically significant. Women who have Medicaid have 30% lower odds of experiencing cardiotoxicity compared with those with private insurance but not statistically significant.
		NA	NA	Community‐level education: OR, 1.04 (95% CI, 0.80–1.34)	A 10% increase in the percentage of individuals with less than a high school education is associated with a 4% increase in the odds of experiencing cardiotoxicity, but it is not statistically significant.
2	Appiah et al 2021 57	Residence (rural vs urban): Unadjusted HR, 1.29 (95% CI, 1.22–1.36) Adjusted for individual level factors (such as race and ethnicity, marital status): HR, 1.08 (95% CI, 1.03–1.13) Adjusted for individual‐level+neighborhood‐level factors (such as SES, primary care provider density): HR, 1.00 (95% CI, 0.96–1.05)	NA	NA	Breast cancer survivors living in rural communities have an elevated risk of CVD death. However, once individual‐level factors are considered, the difference in CVD mortality rates between rural and urban areas becomes statistically insignificant. Neighborhood‐level characteristics explained the rural–urban disparities in CVD death observed among breast cancer survivors.
3	Solanki et al 2016 46	Ethnicity: HR (API vs NHW), 0.77 (95% CI, 0.71–0.83)	NA	NA	Compared with NHW women, API women had a 23% lower risk of cardiovascular death.
4	Litvak et al 2018 43	NA	NA	Race: HR (Black vs White), 2.73 (95% CI, 1.24–6.01)	Black patients have a 2.73 times higher rate of cardiotoxicity than White patients.
5	Connor et al 2022 28	Race: HR (Black vs White), 1.33 (95% CI, 1.17–1.51) HR (Black vs White, among patients without preexisting CVD), 1.43 (95% CI, 1.20, 1.69)	NA	NA	Black women had a 33% higher risk of CVD‐related death compared with White women. Coexisting CVD at cancer diagnosis did not further increase the risk of CVD death in Black women compared with White women.
6	Conroy et al 2023 58	NA	Neighborhood SES: HR (lowest vs highest), 1.38 (95% CI, 0.84–2.26) Racial and ethnic composition Percentage of Asian American/Pacific Islander residents: HR (low vs high), 1.53 (95% CI, 1.09–2.15) Percentage of NHW residents: HR (lowest vs highest), 0.95 (95% CI, 0.55–1.66) Crime Index: HR (high vs low), 1.31 (95% CI, 0.97–1.76) Urbanization: HR (city outside of metro areas vs metropolitan urban), 1.45 (95% CI, 0.95–2.21)	NA	Neighborhood SES, racial and ethnic composition (percentage of foreign‐born residents), Crime Index, and urbanization were not significantly associated with incident CVD events.
7	Troeschel et al 2019 31	Race and ethnicity: Age<55: HR (NHB vs NHW), 3.71 (95% CI, 3.29–4.19) Age 55–68: HR (NHB vs NHW), 2.31 (95% CI, 2.15–2.49) Age>69: HR (NHB vs NHW), 1.24 (95% CI, 1.19–1.30)	NA	NA	There was a monotonic reduction in CVD‐related mortality disparities between NHW and NHB with increasing age.
8	Hashibe et al 2024 56	NA	Composite CVD (ANHPI vs NHW): HR, 0.65 (95% CI, 0.55–0.76) AMI (ANHPI vs NHW): HR, 0.64 (95% CI, 0.46–0.90) HF (ANHPI vs NHW): HR, 0.74 (95% CI, 0.63–0.87) IHD (ANHPI vs NHW): HR, 0.58 (95% CI, 0.47–0.70)	NA	Compared with NHW patients, ANHPI had a lower risk of AMI, HF, and IHD.
9	Berkman et al 2014 34	Ages 40–49: HR (Black vs White), 14.99 (95% CI, 5.39–41.67) Ages 50–59: HR (Black vs White), 6.43 (95% CI, 3.61–11.46) Ages 60–69: HR (Black vs White), 2.26 (95% CI, 1.63–3.14) Ages ≥70: HR (Black vs White), 1.17 (95% CI, 0.99–1.38)	NA	NA	Black women with DCIS had a higher risk of CVD death compared with White women.
10	Tsai et al 2014 36	NA	NA	Household income: cardiomyopathy/HF: HR (below vs above median), 1.14 (95% CI, 1.09–1.20) Race: cardiomyopathy/HF: HR (non‐White vs White), 1.05 (95% CI, 0.98–1.14)	Among older patients with breast cancer treated with trastuzumab, lower household income is associated with a higher risk of cardiomyopathy and HF. Race is not associated with the incidence of cardiomyopathy or HF.
11	Ho et al 2023 51	County‐level SES: HR (lowest vs highest), 1.41 (95% CI, 1.36–1.46) Rurality: HR (highest vs lowest), 1.24 (95% CI, 1.17–1.30)	NA	NA	Breast cancer survivors living in the lowest‐SES counties had a 41% higher risk of CVD death. Women living in the most rural counties had a 24% increased risk of CVD death compared with those in the most urban counties.
12	Raisi‐Estabragh et al 2023 44	10‐y age‐adjusted CVD mortality rate decline: Ethnicity: 58.5% White 47.4% Black 62.5% Asian: Residence 58.5% urban 46.7% rural	NA	NA	Among those with breast cancer, Black women had the smallest cardiovascular age‐adjusted mortality rate decline of all racial groups considered. Urban–rural disparities in CVD death are increased in people with breast cancer.
13	Battisti et al 2022 52	NA	Adjusted OR of CVD hospitalization: Ethnicity (White [reference]): OR (Asian), 1.36 (95% CI, 1.24–1.49) OR (Black), 0.94 (95% CI, 0.82–1.08) Income Deprivation Index (1: least [reference]): OR (for 5), 1.74 (95% CI, 1.65–1.84)	NA	The OR of CVD hospitalization among Asian women is 1.36 times higher than that of White women. However, the OR of CVD hospitalization among Black women is similar to that of White women. The OR of CVD hospitalization becomes greater as the Income Deprivation Index increases.
14	Bostany et al 2024 47	NA	NA	Adjusted HR (NHB/NHW), 2.16 (95% CI, 1.34–3.5)	Among breast cancer survivors exposed to trastuzumab/pertuzumab with or without radiation, the prevalence of cardiotoxicity is 2.16 times higher among NHB women compared with NHW women.
15	Cheng et al 2022 45	CVD death associated with air pollution (nitric oxide, particulate matter) exposure HR for fixed‐size increases in air pollutants: Race and ethnicity HR (Black) (for nitrogen oxides), 3.62 (95% CI, 1.91–6.86) HR (Black) (for particulate matter ≤10 μm), 1.55 (95% CI, 1.04–2.29) Neighborhood SES index (reference was the combination of the lowest nitrogen dioxide level [first quantile] and high neighborhood SES) HR (95% CI) (low neighborhood SES) (for nitrogen oxides), 1.57 (95% CI, 0.99–2.50) HR (95% CI) (high neighborhood SES) (for nitrogen oxides)=0.65 (95% CI, 0.23–1.81) HR (low neighborhood SES) (for particulate matter ≤2.5 μm), 1.43 (95% CI, 0.85–2.42) HR (high neighborhood SES) (for particulate matter ≤2.5 μm), 1.40 (95% CI, 0.59–3.35)	NA	NA	For CVD death, 1.6‐ to 3.6‐fold increased risks of death were seen for all pollutants among Black patients with breast cancer (P value range=0.03 to <0.0001). The risk of CVD death associated with air pollutants was higher among low neighborhood SES than high neighborhood SES cases (P heterogeneity >0.05).
16	Deen et al 2018 40	Ethinicity (Reference: Dutch) HR (for Surinamese), 1.49 (95% CI, 1.13–1.97) HR (for Turkish), 1.96 (95% CI, 1.27–3.01)	CVD admission Ethnicity (Reference: Dutch) HR (for Surinamese), 1.46 (95% CI, 1.29–1.64) HR (for Turkish), 1.25 (95% CI, 1.03–1.51)	NA	Surinamese and Turkish women with breast cancer face greater disadvantages in CVD‐related admissions compared with Dutch women with breast cancer.
17	Hamood et al 2019 53	NA	Outpatient visits per average 10 annual visits: HR, 1.86 (95% CI, 1.50–2.31) Employment transition between breast cancer diagnosis and treatment: job loss vs no change: HR, 29.62 (95% CI, 12.72–68.97) Education (per 1‐y increment): HR, 0.84 (95% CI, 0.75–0.94)	NA	Among breast cancer survivors, a longer duration of education is associated with a decreased risk of CVD, whereas employment change (job loss) and an increased number of outpatient visits are associated with an increased risk of CVD.
18	He et al 2023 38	Race (reference: White) HR (for Black), 1.03 (95% CI, 0.95–1.06) Household income (reference: <$ 60 000) HR (for $\ge$$60 000), 0.89 (95% CI, 0.81–1.01)	NA	NA	Higher household income ($\ge$$60 000) is associated with a reduction in CVD death compared with lower household income (<$60 000) among breast cancer survivors. There is no difference in CVD death between Black and White patients with breast cancer.
19	Koric et al 2022 24	NA	Heart disease 10 y after breast cancer diagnosis: Education (reference: high school) High school or less: HR, 1.41 (95% CI, 1.29–1.54) Some college: HR, 0.89 (95% CI, 0.83–0.96) Beyond college: HR 0.81 (95% CI, 0.72–0.90) Rural residence (reference: urban) Rural: HR, 0.80 (95% CI, 0.63–1.01)	NA	A higher level of education is associated with a lower risk of heart disease among breast cancer survivors. Rural residence is associated with a 20% decreased risk of heart disease compared with urban residence but not statistically significant.
20	Obeidat et al 2024 22	NA	HF Race (reference: White) Black: OR, 1.88 (95% CI, 1.86–1.90) API: OR, 0.89 (95% CI, 0.87–0.92) Native American: OR, 1.16 (95% CI, 1.09–1.23) Hispanic: OR, 1.00 (95% CI, 0.99–1.02)	NA	Black women with breast cancer showed higher risks for all HF types, particularly chronic and systolic, while API patients had a lower incidence of certain HF types compared with White women.
21	Shi et al 2021 27	Standardized mortality ratio: relative risk of death from CVD for cancer survivors as compared with the standard US population Uninsured: 1.83 Medicaid: 2.35 Non‐Medicaid: 0.72	NA	NA	Patients with breast cancer with non‐Medicaid insurance have a significantly lower CVD mortality rate than those with no insurance or Medicaid.
22	Stabellini et al 2024 30	NA	2‐y MACE (a composite of HF, acute coronary syndrome, atrial fibrillation, and ischemic stroke) following the cancer diagnosis HR, 1.10 (95% CI, 1.06–1.13) (for each 1‐point increase in allostatic load before the cancer diagnosis)	NA	A 1‐point elevation in allostatic load (chronic stress) before breast cancer diagnosis corresponded to a 10% heightened associated risk of MACEs.
23	Stabellini et al 2023 23	NA	Adverse SDoH variables for predicting 2‐y MACEs were neighborhood median household income (Shapley Additive Explanations score, 0.07), Neighborhood Crime Iindex (Shapley Additive Explanations score, 0.06), and neighborhood median home values (Shapley Additive Explanations score, 0.03).	NA	Neighborhood variables are the most important SDoH predictors for 2‐y MACEs among breast cancer survivors.
24	Vaynrub et al 2024 29	NA	NA	Compared with NHW, NHB had a higher rate of cardiotoxicity (9.3% vs 17.7%, respectively) and a lower rate of left ventricular ejection fraction recovery (70.6% vs 21.4%, respectively). Race and ethnicity was not a significant predictor of cardiotoxicity after adjusting for CVD risk factor [Reference: NHW]: HR, 1.06 (95% CI, 0.99–1.14)	Trastuzumab‐induced cardiotoxicity was more common among NHB compared with NHW. However, the Black race was not consistently associated with trastuzumab‐induced cardiotoxicity after adjustment for CVD risk factors.
25	Wang et al 2021 50	Race (reference: White) HR (Black), 1.27 (95% CI, 1.11–1.46)	NA	NA	Black patients with breast cancer have a 27% higher risk of CVD death compared with White patients.
26	Zhu et al 2023 54	Race (reference: NHW) NHB: HR, 1.25 (95% CI, 1.21–1.29) Hispanic: HR, 0.84 (95% CI, 0.81–0.88) Non‐Hispanic API: HR, 0.75 (95% CI, 0.72–0.79)	NA	NA	After adjusting for sociodemographic and clinical characteristics, NHB women had a higher CVD mortality rate, whereas Hispanic and API had a lower CVD mortality rate than NHW women.
27	Gernaat et al 2017 32	Ethnicity; Indian vs Chinese: HR, 2.5 (95% CI, 1.2–5.2)	NA	NA	Indian individuals had a 2.5 times higher risk of CVD death than Chinese individuals, independent of age at diagnosis and stage.
28	Azambuja et al 2020 37	NA	NA	Congestive HF (non‐White—difference in incidence [%]) (reference: White): −3.57 (−6.55to ≈−0.59)	The risk of trastuzumab‐associated congestive HF is significantly higher among non‐White compared with White race.
29	Matthews et al 2021 25	NA	Coronary artery disease: HR (White), 0.95 (95% CI, 0.94–0.97) HR (Black), 1.08 (95% CI, 1.02–1.15) MI: HR (White), HR, 0.96 (95% CI, 0.93–0.99) HR (Black), 1.10 (95% CI, 1.00–1.22)	NA	Breast cancer was linked to a higher risk of coronary artery disease and MI in Black women, but it was associated with a lower risk of these conditions in White women.
30	Wang et al 2024 42	Social support (highest vs lowest): HR, 0.92 (95% CI, 0.75–1.14) Social strain (highest vs lowest): HR, 0.80 (95% CI, 0.65–0.99) Social stress (highest vs lowest): HR, 0.90 (95% CI, 0.71–1.12)	NA	NA	Patients with highest social strain was associated with a 20% lower risk of CVD death compared those with lowest social strain. However, there was no significant association between social support, social stress, and CVD death.
31	Yeo et al 2024 55	Age‐adjusted CVD mortality rates per 100 000 individuals Ethnicity: NHB: 1.95 (95% CI, 1.90–1.99), Hispanic or Latina: 0.75 (95% CI, 0.72–0.78) Residence: Rural: 1.64 (95% CI, 1.62–1.67), Urban: 1.55 (95% CI, 1.53–1.56)	NA	NA	NHB patients showed the highest CVD mortality rate, whereas Hispanic or Latina patients had the lowest CVD mortality rate. The CVD mortality rate was higher in rural regions than in urban areas.
32	Bikomeye et al 2025 26	Greenspace (quartiles) Quartile 4 (highest) vs quartile 1 (lowest [reference]): HR (95% CI)=, 0.94 (95% CI, 0.82–1.09) Quartile 3 vs quartile 1: HR, 1.03 (95% CI, 0.96–1.10) Quartile 2 vs quartile 1: HR, 1.09 (95% CI, 0.96–1.16)	NA	NA	Overall, greenspace was not significantly associated with CVD death. However, this relationship varied by region, with greenspace linked to lower CVD mortality rates in California and New Jersey.
33	Bikomeye et al 2025 41	NA	First MACE events by greenspace (quartiles) Quartile 4 (highest) vs Quartile 1 (lowest [reference]): HR 1.04 (95% CI, 0.88–1.23) Quartile 3 vs Quartile 1: HR, 0.80 (95% CI, 0.67–0.97) Quartile 2 vs Quartile 1: HR, 0.82 (95% CI, 0.70–0.96)	NA	Among individuals with breast cancer who have undergone cardiotoxic treatments, greater greenspace exposure is associated with a longer time to the development of MACEs.
34	Kjaer et al 2025 35	Death due to IHD: short education vs long education (reference): HR, 1.54 (95% CI, 1.07–2.24)	NA	NA	Breast cancer survivors with less education had a higher IHD mortality rate than those with more education.
35	Le et al 2025 39	10‐y incidence of MACEs—Black vs White (reference): HR, 1.17 (95% CI, 1.02–1.33) Risk difference (Black – White) (%), 2.32 (95% CI, 0.59–9.69)		NA	Among older patients with breast cancer with anthracycline therapy, MACE incidence was significantly higher in Black than in White patients.
36	Luo et al 2025 48	Race: Black vs White (reference): HR, 1.17 (95% CI, 1.12–1.22) Marital status: Unmarried vs Married (reference): HR, 1.83 (95% CI, 1.78–1.88) Household income ($): >75k vs <55k (reference): HR, 0.79 (95% CI, 0.76–0.82) 55–75k vs <55k: HR, 0.86 (95% CI, 0.83–0.89)	NA	NA	Black patients had a slightly higher risk of heart disease–related death than White patients. Unmarried patients experienced a markedly higher risk of heart‐specific death compared with married patients. Higher median household income was associated with a lower risk of heart‐specific death, particularly for incomes >$55 000.
37	Wadden et al 2025 49	Composite of incident CVD events and cardiovascular death Residence: small rural vs urban (reference): HR, 0.99 (95% CI, 0.63–1.57) Insurance: No insurance vs private (reference): HR (95% CI)=0.94 (0.56–1.58) Household income ($) <20k (lowest) vs ≥50k (highest [reference]): HR, 1.19 (95% CI, 0.92–1.55)		NA	In patients with breast cancer, residence, insurance status, and household income were not associated with an increased risk of composite CVD events and CVD‐related death.

AMI indicates acute myocardial infarction; ANHPI Asian, Native Hawaiian, and Pacific Islander; API, Asian or Pacific Islander; CVD, cardiovascular disease; DCIS, ductal carcinoma in situ; HF, heart failure; HR, hazard ratio; IHD, ischemic heart disease; MACE, major adverse cardiovascular event; MI, myocardial infarction; NA, not available; NHB, non‐Hispanic Black; NHW, non‐Hispanic White; OR, odds ratio; SDoH, social determinant of health; and SES, socioeconomic status.

Figure 3. CVD‐related outcomes disparities among breast cancer survivors.

A, Association between race and CVD outcome disparities. B, Association between residence and CVD outcome disparities. C, Association between community‐level SES and CVD outcome disparities. CVD indicates cardiovascular disease; SES, socioeconomic status; and SDoH, social determinants of health.

Individual‐Level SDoHs and CVD‐Related Outcomes

Race and ethnicity, and individual‐level SES (such as income, education, or health insurance) were 2 key individual‐level SDoHs associated with CVD outcomes among breast cancer survivors. Compared with non‐Hispanic White women, Black women experienced significantly higher risk of adverse CVD outcomes, including CVD death,^* CVD incidence, ²² , ²⁵ , ³⁹ and cardiotoxicity related to chemotherapy. ²⁹ , ³³ , ³⁷ , ⁴³ , ⁴⁷ Those with lower individual‐level SES (income, ³⁶ , ³⁸ , ⁴⁸ education ²⁴ , ³⁵ , ⁵³ ) had an increased risk of CVD and higher CVD‐related death compared with those with higher individual‐level SES.

CVD Death

Race and ethnicity were significantly associated with CVD death among breast cancer survivors across 14 studies, most (n=12) of which were conducted in the United States.^† Several studies reported that Black breast cancer survivors face worse CVD‐related survival outcomes compared with non‐Hispanic White breast cancer survivors.^‡ These studies reported a significantly higher CVD mortality rate in Black breast cancer survivors compared with non‐Hispanic White breast cancer survivors, ranging from 17% to 33% increased mortality risk. ²⁸ , ³¹ , ⁴⁸ , ⁵⁰ , ⁵⁴ Two retrospective cohort studies using the SEER program reported that CVD mortality disparities between non‐Hispanic White and Black survivors decreased as patients became older. ³¹ , ³⁴ Although there was a significant decline in CVD death among breast cancer survivors over the past decade, Black breast cancer survivors consistently exhibited the highest age‐adjusted CVD death. ⁴⁴ , ⁵⁵ Cheng et al ⁴⁵ examined CVD death in association with environmental pollutants among Black survivors and reported a 1.6 to 3.6‐fold increase in risk compared with other racial and ethnic groups. In contrast, Asian or Pacific Islander breast cancer survivors had better survival and a lower risk of CVD death compared with non‐Hispanic White breast cancer survivors. ⁴⁶

Four studies have examined individual‐level socioeconomic factors in association with CVD‐related mortality outcomes. The studies by He et al and Luo et al highlighted that a higher household income (>$60 000 or $55 000, respectively) was associated with a reduced risk of CVD death. ³⁸ , ⁴⁸ Kjaer et al found breast cancer survivors with less education had a higher CVD mortality rate than those with more education. ³⁵ In the study by Shi et al, patients with breast cancer who had non‐Medicaid insurance experienced significantly lower CVD mortality rates compared with those with no insurance or with Medicaid coverage. ²⁷

CVD Incidence

Eight studies examined associations between race and CVD incidence. ²² , ²⁵ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴⁹ , ⁵² , ⁵⁶ Three studies reported that Black breast cancer survivors had a higher incidence of CVD compared with those of other racial or ethnic groups. ²² , ²⁵ , ³⁹ However, another study did not find any difference in CVD‐related hospitalization between Black and White breast cancer survivors. ⁵² The risk of coronary artery disease and myocardial infarction was higher among Black breast cancer survivors, but lower in non‐Hispanic White breast cancer survivors. ²⁵ Black breast cancer survivors had higher risks for all heart failure types, while Asian or Pacific Islander breast cancer survivors had a lower incidence of certain heart failure types compared with non‐Hispanic White breast cancer survivors. ²² Conversely, Asian, Native Hawaiian, and Pacific Islander breast cancer survivors had a lower risk of myocardial infarction, ischemic heart disease, and stroke compared with non‐Hispanic White breast cancer survivors. ⁵⁶ Surinamese and Turkish breast cancer survivors faced more significant disparities in cardiovascular‐related admissions compared with Dutch breast cancer survivors. ⁴⁰

Three studies examined employment status and education in association with CVD risk, reporting increased CVD incidence among breast cancer survivors with unemployment ⁵³ and lower education levels. ²⁴ , ⁵³

Cardiotoxicity

Black breast cancer survivors were disproportionately affected by cardiotoxicity related to cancer treatment as compared with non‐Hispanic White breast cancer survivors. ²⁹ , ³³ , ³⁷ , ⁴³ , ⁴⁷ Al‐Sadawi et al ³³ and Litvak et al ⁴³ reported 1.9‐ to 2.7‐fold increases in the odds of cardiotoxicity in Black breast cancer survivors compared with non‐Hispanic White breast cancer survivors. Vaynrub et al ²⁹ and Bostany et al ⁴⁷ highlighted that Black breast cancer survivors exposed to trastuzumab had increased rates of cardiotoxicity as compared with non‐Hispanic White breast cancer survivors. However, there were inconsistent results about the impact of income level on cardiotoxicity. A study using US Medicare data reported that lower income was associated with a higher risk of cardiomyopathy and heart failure among older breast cancer survivors treated with trastuzumab. ³⁶ Meanwhile, Al‐Sadawi et al ³³ found no significant differences in cardiotoxicity risk on the basis of health insurance type, household income, or community‐level education.

Interpersonal‐Level SDoHs and CVD‐Related Outcomes

Only 2 studies examined the association between interpersonal‐level SDoHs and CVD outcomes among breast cancer survivors. ³⁰ , ⁴²

CVD Death and Incidence

Stabellini et al ³⁰ highlighted the role of chronic psychosocial stress, measured as allostatic load, which increased the risk of major adverse cardiovascular events by 10% for a 1‐point elevation in stress level among breast cancer survivors. However, another study from the Women's Health Initiative found no association between social stress and CVD death. ⁴²

Community‐Level SDoHs and CVD‐Related Outcomes

Community‐level SDoHs were also significantly linked to CVD outcomes. Survivors living in rural areas ⁴⁴ , ⁴⁹ , ⁵¹ , ⁵⁵ and low‐SES neighborhoods ²³ , ⁴⁵ , ⁵¹ had significantly worse CVD outcomes. Furthermore, community‐level SDoHs further exacerbated CVD outcome disparities due to environmental factors like air pollution ⁴⁵ and greenspace. ²⁶ , ⁴¹

CVD Death

Community‐level SDoH determinants were significantly associated with CVD death. Urban–rural disparities were shown to exacerbate cardiovascular death among breast cancer survivors. Rural residence was associated with worse outcomes, with a 24% higher risk of CVD death among women living in rural areas compared with those living in urban areas. ⁵¹ Raisi‐Estabragh et al ⁴⁴ and Yeo et al ⁵⁵ also confirmed persistent urban–rural disparities for at least a decade, particularly in CVD death. However, 1 study did not observe an association between rural residence and CVD death. ⁵⁷ That study noted that breast cancer survivors in rural areas face a higher risk of CVD death; however, accounting for individual‐level factors attenuated these differences. ⁵⁷

Neighborhood SES was also related to CVD death. Ho et al ⁵¹ reported that breast cancer survivors living in the lowest‐SES counties had a 41% increased risk of CVD death compared with those in higher‐SES areas. Cheng et al ⁴⁵ emphasized that low neighborhood SES amplified the adverse effects of air pollutants on CVD death among breast cancer survivors. A study using the USA SEER database found no overall association between greenspace and CVD death but observed that higher greenspace was linked to lower CVD death in certain regions such as California and New Jersey. ²⁶

CVD Incidence

Four studies examined the association between neighborhood‐level characteristics and CVD incidence. In the study by Battisti et al, ⁵² living in neighborhoods with a higher income deprivation index was associated with increased CVD hospitalizations. Stabellini et al ²³ found that neighborhood and built environment factors, such as crime indices and transportation access, were significantly associated with 2‐year major adverse cardiovascular events. Conversely, Conroy et al ⁵⁸ reported no significant association between neighborhood SES, racial or ethnic composition, percentage of foreign‐born residents, crime index, or urbanization with incident CVD events. A single‐hospital retrospective cohort study found greater greenspace exposure was linked to a delayed onset of first major adverse cardiovascular event in US patients with breast cancer who received cardiotoxic treatment. ⁴¹

Summary of the Association Between Various Levels of SDoH and CVD Outcomes Disparities

Figure 3 summarizes disparities in CVD outcomes across key SDoH. Black breast cancer survivors experienced predominantly unfavorable CVD outcomes compared with non‐Hispanic White breast cancer survivors, in CVD death, CVD incidence, and chemotherapy‐related cardiotoxicity, with the most studies (10/11 for CVD death, 5/6 for CVD incidence, 5/6 for cardiotoxicity) reporting unfavorable associations (Figure 3A). Compared with urban settings, rural residence was associated with worse CVD mortality outcomes, although evidence on CVD incidence was limited and largely neutral (Figure 3B). Lower community‐level SES is linked to unfavorable CVD outcomes, particularly in CVD incidence and death (Figure 3C). These findings highlight that SDoHs were significantly associated with CVD outcomes among breast cancer survivors at multiple levels.

Measurement Heterogeneity

This review identified considerable variation in how SDoHs and CVD outcomes were measured across studies. For example, community‐level SES was defined differently in each study, often using composite indices (eg, housing value, poverty level, and education index) yet including various individual indicators. ²³ , ⁴⁵ , ⁵¹ , ⁵⁷ , ⁵⁸ Similarly, the categorization of rurality was inconsistent. Some studies ²⁴ , ⁴⁴ , ⁴⁹ , ⁵⁷ used the Rural–Urban Continuum Codes established by the US Department of Agriculture, while others used different criteria, such as population density or size of census‐designated metropolitan areas, ⁵⁸ the National Center for Health Statistics Urban–Rural Scheme for counties, ⁴⁴ or the 2013 US Census Classifications. ⁵⁵ Similarly, definitions of CVD outcomes varied across studies. Most studies used International Classification of Diseases (ICD) codes to identify CVD events. Cardiotoxicity definitions also differed: Some studies included symptomatic heart failure defined by symptoms and physical examination findings related to heart failure following chemotherapy. ³³ , ³⁷ Other studies defined cardiotoxicity as a decline in left ventricular ejection fraction, measured by echocardiography, specifically if left ventricular ejection fraction drops below 50% or an absolute decrease of 10% or more from baseline. ²⁹ , ⁴³ , ⁴⁷

Risk of Bias

Table 4 summarizes the findings from the Mixed Methods Appraisal Tool quality assessment. All the included studies met at least 3 of the 5 Mixed Methods Appraisal Tool criteria. However, several common issues were identified: (1) incomplete outcome data, with follow‐up information available for <80% of participants in many studies; (2) small sample sizes that prevent the study populations from accurately representing the target population; and (3) 6 studies failed to provide details on potential confounding variables.

Table 4.

Summary of Quality Assessment of Included Studies in the Review (n=37)

Study designs	Quality criteria	Responses (number of studies)
		Yes	No	Can't tell
All	S1. Are there clear research questions?	37	0	0
	S2. Do the collected data allow to address the research questions?	37	0	0
Quantitative nonrandomized	3.1. Are the participants representative of the target population?	30	7	0
	3.2. Are measurements appropriate on both the outcome and intervention (or exposure)?	31	5	1
	3.3. Are there complete outcome data?	21	0	16
	3.4. Are the confounders accounted for in the design and analysis?	31	5	1
	3.5. During the study period, is the intervention administered (or exposure occurred) as intended?	33	3	1

DISCUSSION

Summary of Findings

This systematic review is the first to apply the 2024 AHA SDoH framework, which categorizes factors into individual, interpersonal, and community levels, to examine disparities in CVD outcomes among female breast cancer survivors. By organizing the literature through this multilevel lens, we identified significant gaps in how various levels of SDoHs interact to shape CVD risk in this population. First, with regard to the integration of SDoHs into current research, 37 studies were included, with most conducted in the United States and using retrospective cohort designs. Among these, most studies examined individual‐level SDoHs, such as race and ethnicity, income, and education, while less than half investigated community‐level factors like community or neighborhood SES and rurality. However, only 2 studies addressed interpersonal‐level SDoHs, specifically chronic stress. Second, the review summarized the associations between SDoHs and CVD outcomes. Race and ethnicity were the most studied individual‐level SDoH factors, with consistent findings showing that Black women experienced higher rates of adverse CVD outcomes compared with non‐Hispanic White women, reflecting underlying social and structural inequities rather than biological differences. Community‐level SDoH factors such as low neighborhood SES and living in rural areas were linked to poor CVD outcomes. Breast cancer survivors who lived in low neighborhood SES or rural areas showed a significantly higher risk of CVD death or CVD incidence. Third, disparities in CVD outcomes were associated with SDoHs at all levels, highlighting systemic inequities. However, most studies lacked comprehensive approaches to examining the interplay between SDoH levels, leaving gaps in understanding multilevel impacts.

Race as a Social Construct Reflecting Social and Structural Inequalities

Interpretation of racial and ethnic disparities in CVD outcomes among breast cancer survivors requires careful conceptualization of race as a social construct or a proxy for structural racism rather than a biological risk factor. ⁵⁹ However, most studies included in this review did not conceptualize race as a social construct and instead treated race as a statistical variable, without discussing what this variable represents. Furthermore, few studies investigated the social and structural determinants that shape race‐related disparities in CVD outcomes. Current epidemiologic guidance emphasizes that race reflects social experiences shaped by structural inequities and racism across multiple domains such as housing, education, and health care. ⁶⁰ Therefore, it is important to note that the difference in CVD outcomes between Black and non‐Hispanic White patients is largely driven by societal differences, rather than biological differences. Associations between race and cardiovascular outcomes should be interpreted as capturing the cumulative effects of these structural processes, rather than inherent biological differences. ⁶¹ Future research should use methodological and analytical approaches to measure structural racism. ⁶⁰

Measurement Heterogeneity and Methodological Limitations

Significant heterogeneity in measuring SDoH and CVD outcomes across studies complicates comparisons and evidence synthesis. Inconsistent definitions of SDoHs (eg, community‐level SES, rurality), CVD outcomes (eg, cardiotoxicity), and the use of ICD codes for outcome identification might increase the risk of misclassification. ICD codes, developed for billing purposes, might not accurately capture clinical conditions. Retrospective electronic medical record analyses add to these challenges, as electronic medical records often lack standardized SDoH measures. Inconsistencies in findings, such as the varying associations between community‐level SES and CVD incidence (as seen in studies by Battisti et al, ⁵² Conroy et al, ⁵⁸ Stabellini et al, ²³ and Wadden et al ⁴⁹ ), highlight an urgent need for standardized SDoH definitions and outcome measures and data systems that accurately reflect the social and contextual factors impacting cardiovascular health among breast cancer survivors.

As shown in Table S2, only 6 of the 37 included studies (16.2%) used analytic strategies that we considered adequate for causal inference, defined as the explicit use of causal frameworks or methods (eg, directed acyclic graphs to distinguish confounders from mediators, competing‐risk models, mediation analyses, or inverse probability weighting). Most studies used conventional multivariable or Cox proportional hazards regression models and frequently adjusted for comorbidities and cancer treatments. However, these factors lie on the causal pathway linking SDoHs (eg, race or community‐level SES) to CVD outcomes, raising concerns about overadjustment and attenuation of observed associations. Moreover, few studies explicitly examined pathways through which SDoHs are associated with CVD outcomes across multiple levels (individual, interpersonal, and community), and even fewer evaluated the impact of policy‐level interventions. This gap underscores the need for future research that applies causal inference methods, multilevel modeling, quasi‐experimental, or natural‐experiment designs to evaluate how policies and structural interventions at the community‐level influence SDoHs and subsequent CVD outcomes.

Significant Gaps in Understanding the Association With Multilevel SDoHs and CVD Outcomes

This review identified important gaps in understanding how individual, interpersonal, and community‐level SDoHs are associated with CVD‐related outcomes among breast cancer survivors. The existing evidence from the past 15 years has largely focused on a single level of SDoHs (individual or community‐level SDoH factors), with few studies simultaneously examining SDoHs at multiple levels. Moreover, the interactions between different levels of SDoHs and their combined effects on CVD outcomes were not investigated, leaving important questions unanswered about how different levels of SDoHs together affect cardiovascular health among breast cancer survivors. For example, while rurality ⁴⁴ , ⁵¹ , ⁵⁵ and low SES ³⁵ , ⁴⁸ were independently associated with poorer CVD outcomes, little is known about how these community‐level factors intersect with individual‐level characteristics, such as race or income. Although individual‐level factors like race or ethnicity have been extensively studied, their combined effects with community‐level SDoH determinants, such as neighborhood SES, have rarely been explored. Specifically, while living in a rural area has been linked to higher CVD mortality rates, ⁴⁴ , ⁵¹ the combined effects of rurality with individual‐level factors like race or income remain inadequately understood. Interpersonal‐level SDoHs were notably underexplored, with only 2 studies addressing this area. ³⁰ , ⁴² This lack of attention to interpersonal SDoH determinants represents a missed opportunity to examine modifiable factors, such as social connections, social networks, and interpersonal discrimination, that could serve as potential intervention targets to reduce CVD disparities among breast cancer survivors.

Multilevel Strategies to Address CVD Outcome Disparities

Observed CVD outcome disparities among breast cancer survivors in this review underscore the need for multilevel intervention strategies that address SDoHs across individual, interpersonal, and community domains. Evidence shows that interventions targeting only individual level are often insufficient to reduce health disparities, whereas multilevel approaches that simultaneously address health care access, and community environments are more effective for improving population health. ⁶² In clinical settings, multilevel strategies, such as routine SDoH screening in cancer survivorship care, expanding access to specialized cardio‐oncology services via telehealth, fostering interdisciplinary care teams, and collaborating with community partners to mitigate barriers related to health care access such as transportation and insurance coverage, can promote equitable health care access and help to reduce CVD outcome disparities among cancer survivors. ⁶³

Limitations

This review has several limitations. Most studies were conducted in high‐income countries, particularly the United States, which limits the generalizability of the findings to other geographic regions. Additional research in low‐ and middle‐income countries is needed to understand how SDoHs are associated with CVD disparities among breast cancer survivors across diverse health care and cultural contexts. Despite comprehensive database and manual searches, some relevant studies might have been overlooked because the search was limited to specific databases and only studies published in English were included. The reliance on retrospective studies based on electronic medical records raises concerns about data availability and quality because they are not designed to capture SDoHs systematically. Published studies examining SDoHs and CVD outcomes largely focus on risk factors and adverse outcomes, reflecting a historical emphasis in epidemiology on drivers of disease rather than protective or health‐promoting assets. ⁶⁴ Combined with heterogeneity in study designs, exposure/outcome definitions, and analytic approaches, these limit the feasibility of formal publication bias assessment and may contribute to a predominance of neutral or unfavorable findings. Finally, we analyzed cardiotoxicity and CVD incidence separately because cardiotoxicity reflects cancer treatment–related myocardial injury occurring during or shortly after chemotherapy, whereas CVD incidence reflects longer‐term, multifactorial cardiovascular risk driven by traditional risk factors and SDoHs. Nonetheless, some overlap in outcome classification is possible and should be considered when interpreting these findings.

CONCLUSIONS

In this systematic review of studies addressing disparities in CVD outcomes among breast cancer survivors over the past 15 years, we identified important findings that highlight the significant association between SDoHs and CVD outcome disparities. The findings highlight the need for future research that better reflects the multilevel influences of SDoHs on CVD outcomes among breast cancer survivors. The existing evidence came from retrospective studies in high‐income countries, mainly the United States, with substantial heterogeneity in how SDoHs were measured. This underscores the urgent need for prospective, longitudinal research studies with standardized SDoH assessments across diverse settings. To reduce CVD outcome disparities, it will be essential to integrate multilevel SDoH elements into risk assessments and develop intervention strategies that comprehensively address SDoHs.

Sources of Funding

The authors have no funding sources to declare.

Disclosures

None.

Supporting information

Tables S1–S2

PRISMA Checklist