Heart Disease Risk Climbs Steeply in Long-Term Breast Cancer Survivors, National Survey Reveals

Women who have beaten breast cancer may face an entirely different battle years later: their own hearts. A new analysis of nationally representative U.S. survey data shows that cardiovascular disease among female breast cancer survivors does not fade after the treatment tapes come off. Instead, it climbs steadily with time, reaching its highest prevalence a decade or more after diagnosis — precisely the window in which current clinical guidelines stop recommending enhanced cardiovascular screening.

The study, published in Frontiers in Cancer Control and Society, drew on four years of data from the National Health Interview Survey (NHIS), an ongoing household survey run by the National Center for Health Statistics since 1957. Researchers led by Robina Josiah Willock of Morehouse School of Medicine analyzed responses from 2,495 women with self-reported breast cancer surveyed between 2019 and 2022, after excluding 250 questionnaires with more than 15 percent missing data. Because the NHIS underwent a comprehensive redesign in 2019, the four survey years are directly comparable, giving the team a nationally representative snapshot of the civilian, non-institutionalized population.

The outcome measure was deliberately broad. A survivor was counted as having cardiovascular disease if she reported a physician-confirmed diagnosis of any one of four conditions: angina, stroke, myocardial infarction, or coronary artery disease. The researchers then split the survivors into five cohorts based on time since diagnosis — less than one year, one to under five years, five to under seven years, seven to under ten years, and ten or more years — and examined how cardiovascular disease prevalence shifted across the survivorship trajectory.

The pattern was striking. Among women diagnosed less than a year earlier, 16.4 percent reported cardiovascular disease, a figure that likely reflects the acute cardiotoxic effects of chemotherapy and radiotherapy during active treatment. Prevalence then fell to 10.5 percent in the one-to-five-year cohort and 11.0 percent in the five-to-seven-year group. But after the seven-year mark, the curve bent sharply upward: 13.8 percent of survivors seven to ten years out reported cardiovascular disease, and among those surviving a decade or longer — the largest cohort, with 1,359 women — the figure reached 19.1 percent, the highest of any group.

That inflection point matters because it lands almost exactly where formal surveillance ends. Current U.S. breast cancer follow-up guidelines call for yearly mammograms for the first five years, physical exams every three to six months during the first three years, and every six to twelve months in years four and five. After year five, survivors are generally told they can return to routine annual care. The American Society of Clinical Oncology does recommend an echocardiogram within six to twelve months after treatment for asymptomatic patients at elevated cardiovascular risk, but beyond that horizon, enhanced cardiac monitoring largely reverts to what is standard for older women who never had cancer.

To understand who was most at risk, the team first ran Wald chi-square tests across seventeen sociodemographic, behavioral, and clinical variables. Thirteen were statistically significant, including employment status, marital status, delayed medical care, diabetes, body mass index, physical activity, cholesterol, hypertension, smoking history, self-rated health, age, and years of survivorship. Insurance status, education, race, and recency of a doctor’s visit were not, and were dropped from the final model. The researchers then built a forward stepwise logistic regression — a technique that adds and removes predictors in turn to produce the most parsimonious set of variables — which showed strong overall fit, with a likelihood ratio of 16.51 and a c-statistic of 0.754.

The regression results quantified the risks with unusual granularity. Women aged 85 and older had 9.75 times the odds of cardiovascular disease compared with those under 45, and women aged 66 to 84 had 4.24 times the odds. Survivors who had delayed medical care for a year or more because of cost or other barriers were 79 percent more likely to report cardiovascular disease. Hypertension nearly doubled the odds, raising them by 106 percent. Perhaps most striking was the weight of self-rated health: women describing their health as fair or poor had 8.05 times the odds of cardiovascular disease compared with those rating their health excellent, while those rating it good or very good had 2.41 times the odds. Women who had smoked at least 100 lifetime cigarettes showed a 28 percent increase in odds, a trend that fell just short of conventional statistical significance.

Some findings defied expectations. Insurance status, education, and race and ethnicity — factors repeatedly implicated in cardiovascular outcomes in prior research — showed no statistically significant association in this sample. The authors caution that this may be an artifact of sampling: roughly 84 percent of respondents without cardiovascular disease and 83 percent of those with it identified as white, leaving the survey underpowered to detect disparities affecting Black, American Indian, and Alaska Native women. That gap is consequential, because Black breast cancer survivors are known to experience higher cardiotoxicity, earlier onset of cardiovascular symptoms, and a 40 percent higher breast cancer mortality rate than white women, while American Indian and Alaska Native women face elevated mortality despite lower incidence.

The biological logic behind the survivorship curve is well established. Anthracyclines and fluoropyrimidines can trigger endothelial dysfunction and severe cardiac damage; methotrexate and fluorouracil have been linked to congestive heart failure; and chest radiotherapy disrupts coronary endothelium, raising the risk of coronary artery disease and subsequent hypertension. Layered on top of treatment effects are the shared risk factors that breast cancer and cardiovascular disease have in common — aging, hypertension, diabetes, hyperlipidemia, smoking, and sedentary lifestyles — which compound over the years as survivors age out of intensive oncology follow-up and back into general primary care.

The authors argue the data demand a paradigm shift: cardiovascular screening for breast cancer survivors should be lifelong and risk-stratified according to treatment type and individual health profiles, not capped at five years. Primary care physicians, who see survivors across the continuum of care, are positioned to lead that effort by managing hypertension, diabetes, and cholesterol with widely available medications, counseling on smoking, nutrition, and physical activity, and coordinating with cardio-oncology specialists when needed. Prior research suggests survivors want exactly this kind of lifestyle guidance but often do not receive it clearly. With the population of long-term survivors growing as treatment improves, the study’s central message is hard to ignore: surviving breast cancer is not the finish line — it is the beginning of a decades-long commitment to the heart.

Subject of Research: Cardiovascular disease risk among female breast cancer survivors in the United States

Article Title: Cardiovascular disease risk among female breast cancer survivors: findings from the National Health Interview Survey (2019–2022)

Article References: Josiah Willock, R., Nabi, S. R., Parks, D. C., Qaseem, B. A., & Miles, M. A. (2026). Cardiovascular disease risk among female breast cancer survivors: findings from the National Health Interview Survey (2019–2022). Frontiers in Cancer Control and Society, 4, Article 1628255. https://doi.org/10.3389/fcacs.2026.1628255

Image Credits: AI Generated

DOI: 10.3389/fcacs.2026.1628255

Keywords: breast cancer, cardiovascular disease, cancer survivors, cardio-oncology, NHIS, hypertension, smoking, social determinants of health, survivorship care, cardiotoxicity, health disparities, logistic regression