Greenness Exposure and Mortality Risk in a Cardio-Oncologic Population

Background and aims: Knowledge is lacking on the relationship between greenness and mortality in cancer survivors who experience coronary artery disease (CAD), a cardio-oncologic population. We aimed to investigate the association between residential greenness exposure and all-cause mortality in a cardio-oncologic population.

Methods: Cancer survivors undergoing percutaneous coronary intervention at the Rabin Medical Center in Israel between 2004 and 2014 were included in the study. Clinical data were collected from medical records during index hospitalization and from the Israeli National Cancer Registry. Residential greenness was estimated by the normalized difference vegetation index (NDVI), a satellite-based index derived from Landsat imagery at a 30-meter spatial resolution, with larger values indicating higher levels of vegetative density (ranging between -1 to 1). Mortality follow-up data were obtained through the end of 2021. Cox models were used to assess the hazard ratios (HRs) for all-cause mortality per 1SD increase in NDVI.

Results: Among 1,331 patients analyzed [mean (SD) age, 75.6 (10.2) years, 373 (28%) females], the mean (SD) NDVI within a 300-meter radius was 0.12 (0.03). During a median follow-up period of 12.0 (IQR 9.2-14.7) years, 883 (66%) participants died. After adjustment for potential confounding factors, including residential socioeconomic status, air pollution, and smoking, NDVI was inversely associated with mortality hazard [HR (95% CI) = 0.93 (0.86, 0.99); p=.042]. The association was stronger among individuals with more recently (<10 years) diagnosed cancer [HR (95% CI) = 0.89 (0.81, 0.98); p=.019].

Conclusion: In a cohort of cardio-oncologic patients, greenness was independently associated with lower mortality.